Pre-authorisation request for treatment

Please complete the pre-authorisation form below for veterinary treatment over £500

Please attach a full clinical history and a detailed estimate of the treatment to be provided

About the Policyholder

Policy number *

Policyholder's name *

Policyholder's address *

Policyholder's contact telephone number *

Policyholder's email address *

About the pet

Pet's name *

Pet's breed *

Details of the condition that you are seeking authorisation for *

Date and time the illness/injury was first noticed *

Please specify what procedure or treatment you are planning *

Please tell us the date the procedure is planned * (DD/MM/YYYY)

Total estimated cost for pre authorisation (£) *

Please attach all clinical history * Please attach a full clinical history along with any other supporting documents. If you are uploading multiple documents, please select all files to be uploaded at once.

Please attach the estimate for the required treatment * Please attach an estimate for the treatment required If you are uploading multiple documents, please select all files to be uploaded at once.

About your practice

Practice name *

Practice Address *

Practice Telephone number *

Practice email address *

If this is a referral case, please provide the name, address and telephone number of the referring veterinary practice

Payment options *

Please pay directly to the policyholder's bank account
Please pay the veterinary practice

Dog Insurance

Pre-authorisation request for treatment

About the Policyholder

About the pet

About your practice