Dentistry, Oral Medicine and Surgery

 Referral Form

 

Andrew Duke, D.V.M.

Fellow, Academy of Veterinary Dentistry                                                                 251 633-9633 

1962 Schillinger Rd. S.                                                                               Fax      251 633-3025

Mobile, AL   36695                                                                         info@dukeanimalclinic.com

 

 

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