MaleMale NeuteredFemaleFemale Spayed
Approximate date of birth
Where do you want the clinical treatment 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
Previous Adverse Response to Medications
Any specific concerns regarding anesthesia sensitivity?
Please attach relevant medical and dental records. If able, lab work including CBC and chemistry should be done prior to referral.
*Accepted files: .pdf, .doc, .png, .jpg, .gif
Please have your client contact our office at 205-988-8654 to schedule their consultation and/or procedure.