Consult Form (Veterinarians only)

Are you a pet owner? Please note, Philly Vet Dentist does not work directly with pet parents. If your pet is in need of specialty dental care, please consult with your primary veterinarian first.

I will review each submission and reach out by phone to the attending veterinarian within two business days to discuss scheduling and fees.

Referring Veterinarian Name *

First

Last

Practice Administrator/Billing Contact person: *

First

Last

Email address: *

Veterinary Practice: *

Practice address: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number: *

Patient Name *

Owner's Name *

First

Last

Pet Species *

Breed

Age

Weight (kg)

Sex

Male
Male/Neutered
Female
Female/Spayed

Suspected/Confirmed diagnosis: *

Patient Comorbidities:

Current Medications: (please list dose and frequency)

Current Full mouth radiographs:

Click or drag files to this area to upload. You can upload up to 10 files.

Current Pictures of oral cavity:

Click or drag files to this area to upload. You can upload up to 10 files.

Relevant Test Results: (ex. recent echo report, histopathology results)

Click or drag files to this area to upload. You can upload up to 10 files.

Website

Consult Form (Veterinarians only)

Bringing Advanced Dentistry and Oral Surgery to Your Practice

Questions?

Address

E-Mail

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Hours

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