Animal Dental Specialists / Referral Form

Animal Dental Specialists of Upstate New York

6867 East Genesee Street
Fayetteville, NY 13066

(315)445-5640

www.adsuny.com

After completing the form below, please submit vaccination certificates, any available laboratory results, dental radiographs, and/or any other previous medical history available to our office via email at contact@adsuny.com. Thank you for your referral!

Referral Form

Referring Veterinarian: *(required)*

First Name (required)	Last Name (required)

Referring Hospital Name: (required)

Referring Hospital Address: *(required)*
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Referring Hospital Phone: *(required)*
Phone Type	Phone Number (required)

Referring Hospital E-Mail: :

Client's Name(s): *(required)*

First Name (required)	Last Name (required)

Client's Address: *(required)*
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Client's Phone: *(required)*
Phone Type	Phone Number (required)

Additional Client Phone (if available):
Phone Type	Phone Number

E-Mail Address: :

Pet's Name: (required)

Species: (required)

canine
feline

Patient's Date of Birth: (required) :

Patient's Weight (in pounds): (required)

Patient's Breed: (required)

Patient's Color/Markings:

Gender: (required)

male, intact
female, intact
male, neutered
female, spayed

Use: (required)

pet
working
show

Vaccination Dates (please note date given and duration of immunity): (required)

History and Clinical Findings: (required)

Patient's Medications: (required)

Are you able to examine this patient’s mouth without sedation? (required)

yes
no

Has this patient ever received pre-visit pharmaceuticals? If so, what types and dosages and what were the effects? (required)

Additional Comments:

Radiographs available? Please email to contact@adsuny.com if so. (required)

yes
no

Laboratory results available? Please email to contact@adsuny.com if so. (required)

yes
no

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