Dental Referral Form for Veterinarians

Dental Referral Form

    Date

    Referring Veterinarian*

    Clinic Name*

    Clinic Address*

    Clinic Phone Number*

    Fax

    Clinic Email (for Digital Xray Images)*

    Client Name*

    Phone

    Pet*

    Age*

    Breed

    Sex*

    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

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