Please review the details of the claim that you have provided in the previous steps. If there is anything that you would like to change, you can navigate back to the relevant step using the navigation bar. 

Policy details

Claim number:

Policyholder's name:

Animal's name:

Claim paid to:

Referral details

Animal referred by:

If other veterinary referral -
Name of veterinary practice:
Veterinary practice branch/postcode:
Name of veterinary surgeon:
Email address of veterinary surgeon/practice:

Condition details

Date animal taken ill or injured known:

If date known -
Date animal taken ill or injured:

Date of first examination for this condition:

Date animal was registered at your practice:

Reason for referral:

Pathology that forms first condition:

Type of condition (where applicable):

Details related to condition (if requested): 

Further conditions involved in case: 

If secondary diagnosis made - 
Details of other conditions:
Condition related to each other: . If related, how: 

Animal suffered from condition previously:

If suffered from condition before and secondary diagnosis made -
Which diagnosed condition suffered before:

If suffered from condition previously -
Treatment previously provided for condition: 
Treatment for previous occurence of condition administered:

Current condition indirectly or directly related to any previous accident or illness: 

If current condition indirect or directly related to any previous accident or illness -
How related:

Details of diagnostic techniques carried out: #DiagnosticTechniquesDetails#

Animal referred to another practice for any further diagnostics and/or treatments(s): 

If referred to another practice for any further diagnostics and/or treatments(s) -
Name of veterinary practice:
Veterinary practice branch/postcode:
Name of veterinary surgeon:
Email address of veterinary surgeon/practice:

Treatment details

Details of treatment(s) you have recommended:

Box rest recommended:
If box rest recommended -
Duration of box rest recommended:

Complimentary treatment(s) recommended:

If complimentary treatment(s) recommended -
Type of complimentary treatment(s) recommended:  

Treatment(s) completed:
If treatment(s) completed -
Cost of treatments:
If treatment(s) not completed -
Estimated cost of treatment(s):
Further treatment(s) required:

Diagnosis details

Animal died:

If animal has not been put to sleep -
Could condition lead to a Loss of Use claim:
Details of why condition could lead to a Loss of Use claim:

Loss of animal details (if animal has passed away or been put to sleep)

Animal euthanised:

If animal put to sleep -

Animal euthanised by claiming vet:

If animal not put to sleep by claiming vet: 
Details of person who euthanised animal:
Euthanaised in accordance with BEVA guidelines:

If not euthanised in accordance with BEVA guidelines -
Euthanisia not in accordance with BEVA guidelines explanation:

Other viable treatments options available:

If other viable treatment options available -
Treatment options and why not pursued:

Could the animal have been clinically retired to paddock:

If animal could have been clinically retired to paddock -
Why horse wasn't retired to paddock:

If animal not euthanised -

Animal seen before death:

If animal not seen before death -
Animal last seen prior to death:

Post-mortem taken place:

If post-mertem has taken place - 
Actual cause of death:

Both euthanised and non-euthasised - 

Date of death or euthanasia:
Time of death or euthanisia:

After reviewing and if you are happy with the details that you have provided please advance to the next step of this web form.