ORAL RADIOGRAPHY REVIEW 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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The total size of all the file attachments cannot exceed 30MB.

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.  
PATIENT SIGNALMENT

Client's Name*:

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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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DETAILED ORAL EXAM

Please give your findings on a detailed oral examination under general anesthesia*:

A value is required.

Most recent dental chart:

ORAL RADIOGRAPHY

Please attach one or multiple digital radiographs for review:

Dental/oral films are being sent by mail*:

Please make a selection.

Is this an urgent request with your patient under general anesthesia?* *:

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If your request is urgent we will call with our assessment as soon as possible if we are available. There is an additional emergency fee of $ 100.00 + .H.S.T..

Otherwise, we will send our report by e-mail. Diagnosis and treatment recommendations will be made if possible, depending upon the quality of the radiographs submitted for review. The cost for the service is $ 60.00 + H.S.T. per case for 1 radiograph, $90.00 + H.S.T for 2 to 3 radiographs, and $ 120.00 + H.S.T. for more than 3 radiographs. If a hard copy dental/oral film or films are sent by regular mail or courier, they will be returned to your hospital. We will e-mail an invoice to your hospital with our report. Please make your cheque payable to “Animal Dental Care” to be sent to the above address.