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

*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
Endocrine disease
Neurologic disease
Renal disease
Hepatic disease
Gastrointestinal disease
Airway disease
Bleeding/clotting disorders
Other
Previous anesthetic complications

Client Information

Referring Hospital Information

Please attach all relevant documents.

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