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info@companiondentistry.com

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Veterinary Referral Form

If you are a veterinarian who is referring patients, kindly complete the following form.

Veterinary Referral Form

Please submit any relevant documents pertaining to the situation of your patient. The Companion Dentistry and Oral Surgery appreciates your decision. We are glad to work with you!

Client Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Name *

Date of Birth *

Sex *

Male
Female

Weight *

Breed *

Color *

Neutered or spayed *

Referring Veterinarian Please Complete the Following

Referring Veterinarian *

Clinic *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Fax

E-mail *

How would you like to be contacted?

Phone
Email
Fax

Reason for Referral/Working Diagnosis: *

History / Medical Conditions: (Please forward pertinent test results) *

Treatments / Medications *

Pertinent Information Regarding this Case *

Please upload lab reports, x-rays, and other diagnostics.

Click or drag a file to this area to upload.

Additional Upload (if necessary)

Click or drag a file to this area to upload.

As the referring veterinarian, my expectations for this case are as follows: (Please check one.) *

Referral for procedure(s)
Hospitalization and definitive care
Overall management of care for the diagnosis
Overnight care and return in the morning

Is there any more information we should know?

Signature *

Clear Signature

Date *

Message

Ready to Book an Appointment?

We look forward to helping your pet with all their dental needs! To get started, click the button below and schedule a consultation.

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Get in Touch

Have a question? Get in touch through the contact form below.

Name *

First

Last

Email *

Phone

How can we help you? *

Phone

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Send Us An Email

info@companiondentistry.com

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Give Us A Call

(970) 331-0453

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Our Hours

8:00am – 5:00pm Monday-Friday

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Areas We Serve

Colorado’s Western Slope, the Roaring Fork Valley, and Vail Valley.

Aspen, Basalt, Carbondale, Willits, Glenwood Springs, Eagle, Edwards, Avon, Vail, Minturn, Paonia, Hotchkiss, Delta, Gunnison, Grand Junction, and Steamboat Springs.