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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Orlando Veterinary Dentistry

Orlando Veterinary Dentistry