Species: CanineFeline
Sex MaleMale NeuteredFemaleFemale Spayed
Approximate date of birth
Does this pet have a heart murmur? YesNo
Heart murmur grade? Grade IGrade IIGrade IIIGrade IVGrade VGrade VI
If yes, when was it diagnosed? Has it been diagnostically evaluated?
Where you want dental records and discharge information sent
Reason for Referral. Please include any additional information, such as previous treatments or adverse reactions to medications.
Previous Treatment and Response
List of Major Medical Problems
Current Medications
Previous Adverse Response to Medications
Any specific concerns regarding anesthesia sensitivity?
Please attach relevant medical and dental records including dental radiographs. If able, lab work including CBC and chemistry should be done prior to referral.
*Accepted files: .pdf, .doc, .png, .jpg, .gif File size limit: 6MB
Please email any additional records or patient information to our team via email at ads.receptionist@gmail.com.
Please have your client contact our office at 205-988-8654 to schedule their consultation and/or procedure.
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