Veterinary Dental Referral Form 2

Images, both dental radiographs and photographs of the oral cavity, are extremely helpful in determining the urgency of each referral. Please attach images to the appropriate referral form along with patient medical records.

Specific Reason for Referral (be as detailed as possible)

Referring DVM Information:

Name of Hospital or Clinic

Veterinarian

Does the VDCNC team need to contact the rDVM prior to reaching out to the pet owner?

rDVM Email *

rDVM Phone

rDVM Fax

Referring Hospital Email Address *

Patient Information:

Pet Name

Is this a DVM personal pet? *

Breed

Patient Weight *

Color

Sex

Age / Date of Birth

Rabies Vaccination Expiration Date *

Will the patient allow an awake oral exam? *

Client Information:

Owner’s Name

Owner's Phone Number

Owner's Email *

Client Communication: VDCNC's staff will email the referred pet's owner within two business days to continue the referral process.

rDVM Patient Records:
Please submit the following information for the referred pet via an attachment below:

Attach Doctor's notes