TestPatient Referral FormDate: DD slash MM slash YYYY Client InformationFirst and Last Name: First Last Alternate Contact (if needed):Address: Street Address City State / Province / Region ZIP / Postal Code Email (For Medical Record/Reminders): Primary Phone: Home Mobile Work Text Enabled Secondary Phone: Home Mobile Work Text Enabled Patient InformationName of Pet:Species: Canine Feline Breed:Color:Age/DOB: DD slash MM slash YYYY Sex: Male Neutered Female Spayed Name of Family Veterinarian:Name of Hospital:Reason for Visit:List of Major Medical Problems:List all medications/Doses/Frequencies:Is your pet allergic to any medications?History of Dental or anesthetic related problems/treatments:Date of Last professional dental cleaning: DD slash MM slash YYYY Any Extractions?Do you perform Home Dental Care such as brushing?Current Diet:Toys or treats that may have been provided: Please Check Pig ears Cow hooves Antlers Tennis balls Sticks Nylon bones Rawhides Frisbees Ice cubes Rocks Rope toys Bones Cages Other Dental related signs you may have noticed: Please Check Fractured or Broken Teeth Discolored Teeth Bad breath Scratching at the Face Persistent or Recurrent Facial Swelling Reluctance to Chew Hard Toys or Food Drooling or Dropping Food Retained Baby Teeth Loose Teeth Growths on the Tongue Lips or Gums Bleeding Gums Other Dental Radiograph or Case Consultation FormDate: DD slash MM slash YYYY Referring Veterinarian InformationReferring Doctors Name:Name of Hospital:Hospital Phone Number:Preferred time to call: : Hours Minutes AMPM AM/PMHospital email address: Patient InformationName of Pet: First Species: Canine Feline Breed:Age/DOB DD slash MM slash YYYY Sex: Male Neutered Female Spayed Relevant case history including clinical symptoms, oral findings and any specific concerns or questions you would like answered:Upload Relevant Case Files/Images: Drop files here or Select filesMax. file size: 256 MB.History of Dental Problems/Treatments:Please submit all dental radiographs and/or case images in JPEG format via our online portal or email.Consultation requests are reviewed within one business day of submission. If you have an urgent case, please call the Florida Animal Dentistry & Oral Surgery Center directly at (561) 515-6711. Dental and Oral Surgery Referral FormDate: DD slash MM slash YYYY Referring Veterinarian InformationReferring Veterinarian:Referring Animal Hospital:Address (only if first referral): Street Address City State / Province / Region ZIP / Postal Code Phone:Fax:Email: How would you like to receive case reports? Fax Mail Email Please indicate if you would like to also be contacted by phone Yes No Please indicate if you would like us to contact this client? Yes No, Client will contact you. Patient InformationClient Name:Client Home Phone:Mobile Phone:Client Email: Name of Pet: First Species: Canine Feline Breed:Age/DOB DD slash MM slash YYYY Sex: Male Neutered Female Spayed Reason for Referral?Please list any relevant medical and dental history:Current medications or supplements: (Doses / Frequencies / Duration)History of Anesthetic related problems / Drug reactions:Additional Information or Comments:To allow your patients visit to run as smoothly as possible please provide any relevant records and diagnostic test results including any lab and/or radiographic findings via our online portal, email (Office@FloridaAnimalDentistry.com) or fax (561) 515-6711. Please submit all dental radiographs and/or case images in JPEG format via our online portal or email.Upload Case Files / Images Drop files here or Select filesMax. file size: 256 MB.Thank you for the Referral. We strive to provide the best possible care for your patients. Please do not hesitate to contact us if you have any questions regarding this referral.
