Dental Referral Form

Please complete this form and return it along with all radiographs, bloodwork results and medical history within 48 hours of receipt to [email protected]. Please Note: The following vaccinations and diagnostics are required to be current for all non-emergency dental procedures:
Canines: Rabies, DHPP and a negative heartworm test.
Felines: Rabies and FVRCP

Date

Referring Clinician

Phone Number

Clinic Name

Client Information

Name

Phone Number

Patient Information

Pet Name

Age / DOB

Species

Sex

Male

Female

Breed

Color

Referral Information

Reason for Referral / Chief Complaint

Is this an urgent referral?

Yes

Vaccination Due Dates

Rabies Date

DHPP Date

FVRCP Date

Diagnostics / Procedures Due Dates

Heartworm Test (neg) Date

CBC Date

Full Chemistry Date

Known Systemic Health Concerns?

Disease Conditions

Date of Diagnosis

Is the patient receiving medical therapy for this condition?

Current Medications

Drug

Dose (mg)

Frequency

Route (PO/SQ/TM/etc.)

Any known allergies, drug reactions or sensitivities?

Yes

If Yes, explain:

Dental Referral Form

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