Online Referral Form

To be completed by Veterinary Professionals only

Hello, Welcome to Blaise Referral Hospital

For routine referrals, please complete the online form below and we will liaise with our teams and come back with suitable appointment options and an estimate of treatment.

SHOULD YOU NEED US URGENTLY, please call 0121 238 2000 and speak to one of our ECC clinicians.

We look forward to working with you and your teams and meeting your clients and their pets.

Pet owners are reminded that referrals must come from a vet. Submissions from pet owners will not be processed.

Client Details

Vet Details

Referral Details


Please attach the appropriate case history and any additional records e.g. test results, radiographs, ECG tracings etc (Max total file size 8MB).

Pet Details

*All fields are mandatory*

Financial Details

*All fields are mandatory*

Security Question: