Veterinary Dental Referral Form

Primary Reason for Referral

Referring DVM Information:

Name of Hospital or Clinic

Veterinarian

rDVM requests phone consult:

Yes
No

rDVM Email *

rDVM Phone

rDVM Fax

Referring Hospital Email Address *

Patient Information:

Pet Name

Breed

Color

Sex

M
MN
F
FS

Age / Date of Birth

Rabies Vaccination Expiration Date *

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

Click or drag a file to this area to upload.

Attach laboratory results, including histopathology results

Click or drag a file to this area to upload.

Attach previous dental charts

Click or drag a file to this area to upload.

Attach previous anesthesia summaries

Click or drag a file to this area to upload.

Attach dental radiographs

Click or drag a file to this area to upload.

If you have more photos or files to send, please email them directly to info@vdcnc.com. Referral requests are reviewed within one business day of submission. VDCNC hours of operation are Monday-Thursday, so referrals submitted on Thursday and Friday will be reviewed on the following Monday. *

I have read and understand.

Applicable medical records and dental radiographs (if available) must be attached to each patient referral.

Name