New Referral

New Referral Form

At Animal Dental Care & Oral Surgery, we’re here to support you and your patients.

Please complete the referral form below with as much detail as possible, and our team will follow up directly with your client.

If you prefer your client to contact us directly to schedule their visit, they can reach us at 719-536-9949. We’ll do our best to get them seen as soon as availability allows.

Client Info

Patient Info

Species: CanineFeline

Sex

Approximate date of birth

Hospital Info

Where you want dental records and discharge information sent

Patient Medical Info

Reason for referring this pet

Previous Treatment and Response

List of Major Medical Problems

Current Medications

Previous Adverse Response to Medications

Any specific concerns regarding anesthesia sensitivity?

Please attach relevant medical and dental records. If able, lab work including CBC and chemistry should be done prior to referral.

*Accepted files: .pdf, .doc, .png, .jpg, .gif
File Size Limit: 6MB

Please have your client contact our office at 719-536-9949 to schedule their consultation and/or procedure.