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

Yes with Explanation

Endocrine disease

Yes with Explanation

Neurologic disease

Yes with Explanation

Renal disease

Yes with Explanation

Hepatic disease

Yes with Explanation

Gastrointestinal disease

Yes with Explanation

Airway disease

Yes with Explanation

Bleeding/clotting disorders

Yes with Explanation

Other

Yes with Explanation

Date of most recent examination and labwork

Current medications and dosages:

Previous anesthetic complications

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.

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One file only.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Signature

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Dentistry and Oral Surgery service Form