Oral Radiography Review Form

Please complete all required fields marked with *

Date:

The total size of all file attachments cannot exceed 30MB.

REFERRING VETERINARIAN INFORMATION

Referring Veterinarian *

Hospital Name and Mailing Address *

Telephone Number *

E-mail Address *

PATIENT SIGNALMENT

Client's Name *

Patient *

Species *

Date of Birth *

Sex *

Breed *

DETAILED ORAL EXAM

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

Most recent dental chart:

Click to upload or drag and drop

PDF, DOC, DOCX, RTF, TXT, JPEG, JPG, PNG

ORAL RADIOGRAPHY

Please attach one or multiple digital radiographs for review: (25 files max)

Click to upload or drag and drop one or more

Up to 25 files • PDF, DOC, DOCX, GIF, JPEG, JPG, PNG, RTF, TXT, ZIP

Dental/oral films are being sent by mail *:

YesNo

If your patient is under general anesthesia and you need an answer immediately, please complete and submit this form, then contact us at 519-837-3264. *

Yes - UrgentNo - Regular

There is an additional emergency fee of $190.00 + 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.