Dentistry, Oral Medicine and Surgery
Referral Form
Andrew Duke, D.V.M.
Fellow,
Owner
_____________________________
Patient
_____________________________ Species
________________ Breed
___________
Sex __________ Age ________
Weight _______
Pertinent History ______________________________________________________________________
____________________________________________________________________________________
Assessment/Diagnosis _________________________________________________________________
Treatments – Duration and
dosage
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Y N
Have you done diagnostic blood work in the past month? If so, please send results.
Y N
Has the patient undergone anesthesia in the
past month? Please note in treatments.
Y N
Is the patient current on vaccinations and parasite control?
How would you rate the
patient’s suitability for general anesthesia?
Referring
Veterinarian ______________________________________________
Address
_________________________________________________________
City, State, Zip Code
_______________________________________________
Phone__________________________ Fax ________________________
E-mail ____________________________________
For driving directions, see
our web site www.dukeanimalclinic.com