Dental Referral Form

Date

Referring Veterinarian*

Clinic Name*

Clinic Address*

Clinic Email (for Digital Xray Images)*

Pet*

Reason for referral

Pertinent history

Current treatments and/or medications

Please send file attachments (including .jpgs of radiographs) to Annie at annielvt@gmail.com

Please have diagnostic tests performed at your hospital ( labs required no more than 2 months prior to scheduled appointment)

Please fax bloodwork and current records to 800-553-6014