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College of Veterinary Medicine 
Veterinary Hospital

Dentistry Referral Form

This service is for veterinarians only – clients seeking medical information should contact their regular veterinarian for assistance.

Patient Dentistry Form

Status of Referral

Veterinarian Contact Information

Owner Contact Information

Name of the owner(Required)
Address

Information about the patient

Has this patient ever been seen by any service at NC State Veterinary Hospital?
Patient/Pet Name(Required)
Species(Required)
MM slash DD slash YYYY
Gender

Vaccine status

MM slash DD slash YYYY
Rabies vaccination type
Diagnostic data obtained and to be sent with referral
Pictures of a patient’s oral mass/dental disease can helpful in discussing a case prior to presentation and determining the urgency in obtaining a referral appointment

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