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