Skip to main content
Menu
School of Veterinary Medicine
Open Search
Close Search
Search the site:
Main navigation (extended config)
About Us
+
Leadership
Faculty
Departments
Achievements
Community / Outreach
Contact / Directions
Education
+
DVM Admissions
DVM Program
Tuition/Financial Aid
Graduate Programs
Internships / Residencies
Continuing Education
Student Life
+
Academic Calendar
Clubs and Leadership
Career Resources
Mental Health & Wellness
Diversity
Externships
Hospital
+
Emergency 24/7
Appointment / Referrals
Small Animals
Equine / Livestock
Pharmacy / Laboratories
Clinical Trials
Research
+
Research Centers & Laboratories
Graduate Education
Student Research
Global Programs
Resources & Collaborations
Events & Publications
News
+
Latest News
Events Calendar
Publications
Success Stories
Social Media / Blog
Multi-Media
quick-links
+
Giving
Contact / Directions
News
Admissions
Alumni
Faculty
Future Veterinary Medical Center
Vet Med Extension
Canvas
Campus Directory
VIPER
VMACS
Coronavirus Information
COVID-19 Information and Updates
For hospital clients and referring vets
COVID-19 Daily Symptom Survey
Dentistry and Oral Surgery service Form
Breadcrumb
Home
Veterinary Hospital
Small Animal Clinic
Dentistry and Oral Surgery Service
Dentistry and Oral Surgery service Form
Dentistry and Oral Surgery service Form
Thank you for referring your client and patient to the UC Davis VMTH Dentistry and Oral Surgery Service. Please provide the following information in order to help us schedule a consultation appointment. Please note that if this information is not provided, there will be a delay in scheduling your patient.
If you feel that your patient is experiencing an emergency, please call the Emergency Admissions office at (530) 752-1393.
The following form should be filled out by the referring veterinarian.
Referring veterinarian signature required at bottom of the document.
Patient Information
Pet Name
Signalment
Reason for referral
Current/relevant medical history
*
Please provide a brief summary of the patient’s history, pertinent exam findings, recent and relevant diagnostics performed.
Health questionnaire
Does the patient have any of the following medical disorders?
Cardiac disease
No
Yes with Explanation
Yes with Explanation
Endocrine disease
No
Yes with Explanation
Yes with Explanation
Neurologic disease
No
Yes with Explanation
Yes with Explanation
Renal disease
No
Yes with Explanation
Yes with Explanation
Hepatic disease
No
Yes with Explanation
Yes with Explanation
Gastrointestinal disease
No
Yes with Explanation
Yes with Explanation
Airway disease
No
Yes with Explanation
Yes with Explanation
Bleeding/clotting disorders
No
Yes with Explanation
Yes with Explanation
Other
No
Yes with Explanation
Enter explanation
Date of most recent examination and labwork
Current medications and dosages:
Previous anesthetic complications
No
Yes with Explanation
Yes with Explanation
Client Information
Client first and last name:
Client phone number:
Referring Hospital Information
Hospital name:
Referring veterinarian name
Referring veterinarian phone number:
Referring veterinarian email:
Please attach all relevant documents
.
Upload File Here
One file only.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
Signature
Sign above
Leave this field blank