Veterinary Dental Referral Form

Is this case urgent

Referring DVM Information:

Name of Hospital or Clinic

Veterinarian

rDVM requests phone consult with Dr. Hoover:

rDVM Email

rDVM Phone

rDVM Fax

Patient Information:

Primary Reason for Referral

Pet Name

Breed

Color

Sex

Age / Date of Birth

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

Attach laboratory results, including histopathology results

Attach previous dental charts

Attach previous anesthesia summaries

Attach dental radiographs

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.

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