MaleMale NeuteredFemaleFemale Spayed
Approximate date of birth
Where you want dental records and discharge information sent
Reason for referring this pet
Previous Treatment and Response
List of Major Medical Problems
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.