CVC Referral Form

What clinic are you planning on attending?

Name

First

Last

Email

Phone

Have you/the client attended or sought support from the AWLQ Community Vet Clinics previously

a Name client

Name

Species/Breed

Age

Injury/Illness

Veterinary Treatment Required

Is the Veterinary Care

Referring Veterinarians Prognosis (referring vet to complete) -- Leave blank if unknown

Patient History:

Referring veterinary clinics please upload the patient's medical history.
Please contact your usual vet clinic and request that the history be emailed to our clinics

Please give your vet the correct email of the clinic in which you plan to visit. Gold Coast - [email protected] Brisbane - [email protected] Ipswich - [email protected]

Have you/the client been declined for funds with a credit provider?

Yes
No - please proceed with loan applications. Payment support is unable to be provided unless funding has been applied for and evidence provided.

Which loan providers has been applied for?

Do you/the client have a source of income?

Is there other information that you can provide to help us understand your support needs so that we can tailor payment support for you and your pet?

Please upload patient's medical history here.

Click or drag files to this area to upload. You can upload up to 3 files.