Animal Dental Specialists of Upstate New York

6867 East Genesee Street
Fayetteville, NY 13066


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  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 TypePhone 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 TypePhone Number (required)
Additional Client Phone (if available):
Phone TypePhone Number
E-Mail Address: :
Pet's Name: (required)

Species: (required)


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)


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)

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 if so. (required)


Laboratory results available? Please email to if so. (required)


Verify the reCAPTCHA:

 HOURSclock icon

Day Open Close
Monday *7:00am 6:00pm
Tuesday *7:00am 6:00pm
Wednesday *7:00am 6:00pm
Thursday *7:00am 6:00pm
Friday 8:00am 1:00pm
Saturday Closed Closed
Sunday Closed Closed

*Scheduled surgical procedure days.



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Phone:  315-445-5640




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Fear Free Certified Professionals

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