Animal Dental Specialists / Referral Form

Animal Dental Specialists of Upstate New York

6867 East Genesee Street
Fayetteville, NY 13066

(315)445-5640

adsuny.com

For a printable version please click here.

Referring Veterinarian (required)

First Name (required)	Last Name (required)

Referring Hospital Name (required)

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

Referring Hospital E-Mail (required) :

Client's Name (required)

First Name (required)	Last Name (required)

Additional Client Name (if applicable)

First Name	Last Name

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

Additional Client Phone (if available)
Phone Type	Phone Number

Client 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 (required)

Sex (required)

male, intact
male, neutered
female, intact
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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