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:

*=Required

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

REFERRING VETERINARIAN INFORMATION

Referring Veterinarian*:

A value is required.  

Practice Name*:

A value is required.  

Street Address*:

A value is required.  

City/Province*:

A value is required.  

Postal Code*:

A value is required.  

Telephone Number*:

 A value is required.  

E-mail Address*:

A valid email is required.  
CLIENT INFORMATION

Client First and Last Name(s)*:

 A value is required.  

Street Address*:

 A value is required.  

City, Province*:

 A value is required.  

Postal Code*:

 A value is required.  

Home Phone*:

 A value is required.  

Cell Phone:

  

E-mail address:

 
PATIENT SIGNALMENT

Patient*:

 A value is required.

Species*:

 A value is required.

Date of Birth*:

 A value is required.

Sex*:

 A value is required.

Breed*:

 A value is required.

Colour*:

 A value is required.

Recent Weight (kg)*:

 A value is required.

Will your canine or feline patient allow a detailed oral examination when awake?


If not, we require preappointment sedation and recommend the following protocol for both dogs and cats: Gabapentin 20 mg/kg PO and trazadone 5 mg/kg PO by 7:00 am on the morning of your patient's visit with us

Have you or will you be dispensing preappointment sedation for this patient as per the requirement above?

PRESENTING COMPLAINT

When was this first noted?

  

Please describe the dental/oral pathology*:
A value is required.

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? 
 

Whenever possible please take sharp, close-up digital photo images of your patient's mouth and attach below.

If your patient requires sedation just for you to do an oral examination, please make sure to take digital photo images to send as attachments below.

Digital photo image(s):

  

MEDICAL HISTORY

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”*:
A value is required.

CURRENT MEDICATION

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

If your patient has painful dental or oral pathology, whether or not he or she is showing clinical signs of pain, please dispense analgesics and provide us with the details below. We typically recommend gabapentin at a dosage of 10 mg/kg PO q8-12h for both dogs and cats.

If there are any pulp exposed teeth or if there is stomatitis with mucosal inflammation and ulceration beyond the gingiva, analgesic and antibiotic therapies are indicated. We recommend amoxicillin and clavulanic acid at a dosage of
12.5 mg/kg PO q12h for both dogs and cats if there is no hypersensitivity to this antibiotic. We strongly recommend against antibiotic pulse therapy as this is ineffective, and risks the development of antibiotic resistance.



A value is required.

INSURANCE INFORMATION/ SPECIAL REQUESTS

Pet Insured?

Pet Insurance Company:

Preapproval estimate required for Pet Insurance Company?

Special Requests: