Dentistry and CBCT Referral

• Appointment Type:
  Select Appointment TypeDentistryCBCT

• If CBCT, what is the concern?
  Select ConcernEarNasalOther

   

• Client Information:

• First Name:
  

• Last Name:
  

• Address:
  

• City/Town:
  

• Postal Code:
  

• Home Phone:
  

• Cell/Other:
  

• E-mail:
  

• Patient Information:

• Name:
  

• DOB:
  

• Sex:
  MMNFFS

• Species:
  

• Breed:
  

• Colour:
  

• Weight (kg):
  

• Temperament:
  GoodNervousMay BiteMuzzle

• Status

• EmergencyUrgentNext Available

• Emergency & Treatment Authorization

• If our team feels that your patient could benefit from same day treatment, can this occur without contacting you?
  Select OptionYesNo

• Patient History:

• Has bloodwork been done within the last 6 months?
  YesNoSent

• Have chest radiographs been obtained?
  YesNoSent

• Have dental radiographs been obtained?
  YesNoSent

• Has ultrasound/echo been performed?
  YesNoSent

• Has the patient been diagnosed with any of the following?
  Heart DiseaseLiver DiseaseSeizureKidney DiseaseDiabetesRespiratory DiseaseNone

• Has the patient shown any of the following clinical signs?
  CoughingSneezingVomitingDiarrheaOtherNone

• Please send all radiographs and relevant lab work to reception@deanparkpet.com

• Reason For Referral

• Current Concern(s):

• Relevant history, current treatment/medications:

• Please attach all relevant records, radiographs and lab work.

• You may attach up to 10 files. Maximum size per file: 30MB.

Please Note: We encourage you to recommend and perform blood tests prior to dental referrals, including T4 in cats 7 years or older. Once we receive your referral we will contact the client to arrange their appointment. We will email the final report to the referring hospital after consultation and dental procedures have been performed.

Dean Park Pet Hospital

1700 McTavish Rd. North Saanich

E-mail: reception@deanparkpet.com

Phone: 250-656-9911