REFERRAL REQUEST FORM
Dr. Ian J. Haws
Guelph Veterinary Specialty Hospital
1460 Gordon Street
Guelph, Ontario 
Canada      N1L 1C8
Phone: 519 - 837 - FANG/3264
E-mail: info@animaldentalcare.com

Date:

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REFERRING VETERINARIAN INFORMATION

Referring Veterinarian*:

A value is required.  

Hospital Name and Mailing Address*:

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A value is required.  
A value is required.  

Telephone Number*:

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E-mail Address*:

A valid email is required.  
CLIENT INFORMATION

Client's Name*:

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Address*:

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A value is required.  
A value is required.  

Home Phone Number*:

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Cell Phone Number:

 

E-mail address:

 
PATIENT SIGNALMENT

Patient*:

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Species*:

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Date of Birth*:

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Sex*:

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Breed*:

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Colour*:

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Recent Weight (kg)*:

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PRESENTING COMPLAINT

Please describe the dental/oral pathology*:

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PROFESSIONAL DENTAL CARE HISTORY

Most recent professional dental cleaning and assessment:

 

Most recent dental chart:

 

Please give your summary of a detailed oral examination under general anesthesia:

Digital oral radiography: 

 

Dental/oral film  

 

-  being mailed prior to consultation? 

 

-  owner to bring to consultation? 

 

Digital photo image(s):

 

MEDICAL HISTORY

Preanesthetic blood diagnostic testing done*:

Please make a selection.

Diagnostic blood test results:

Other medical diagnostic test results:

Please give any current medical problems that could affect general anesthesia (e.g. cardiac disease, chronic renal failure, any complications during previous anesthesias/ recoveries, known drug adverse reactions, etc.). Otherwise, please enter “None”*:

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CURRENT MEDICATION

Please give current medication, dosage, frequency, and dates started and finished. Otherwise, please enter “None”*:

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INSURANCE INFORMATION/ SPECIAL REQUESTS

Pet Insured?

Pet Insurance Company:

Preapproval estimate required for Pet Insurance Company?

Special Requests: