Animal Dental Clinic of Pittsburgh

9117 Marshall Road
Cranberry Township, Pennsylvan 16066

(724)475-3566

www.animaldentalclinicpgh.com

Referral Form

 

Referring Veterinarians: Please fill out the form below and submit the form electronically or click HERE to print a PDF version and fax it to 1-888-698-3887.

 

Referral Form

Date (required) :
REFERRAL INFORMATION
Referring Veterinarian: (required)

Practice Name: (required)

Telephone Number: (required)

Fax Number:

Clinic Email for Communications: (required) :
OWNER INFORMATION
Owner's Name: (required)
First Name (required)
Last Name (required)
Phone Number: (required)
Phone TypePhone Number (required)
Address: (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
E-Mail Address: (required) :
PATIENT INFORMATION
Patient Name: (required)

Weight (kgs): (required)

Age: (required)

Species: (required)

Breed: (required)

Sex: (required)

Male
Male Neutered
Female
Female Spayed


Vaccine Status: (required)

Reason for Dental Referral: (required)

Priority: (required)

Urgent
Not Urgent
Consult Only


Pertinent History and Other Medical Issues:

Lab Results (email blood work, biopsy reports, photos and dental x-rays):

Medications (Dosage/Duration/Response):

Remarks or Requests:


**Please submit patient records, dental images, bloodwork and any biopsy results via email to adcreferrals@animaldentalclinicpgh.com for review to help plan for your patient’s dental appointment.

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