Dental Referral Form LCVC

Lake County Veterinary Clinics, PLLC
Patient Referral Information

Date of Referral

Referring Doctor

Referring Hospital

Hospital Phone#

Referring office email for referral letter

example@example.com

Owner's Name

Owner's Phone Home:

Owner's Phone Cell:

Owner's Address

Owner's Email

example@example.com

Pet's Name

Age

Weight

Sex

Breed

Referred for:

1.

2.

3.

Brief History of current problems:

Diagnostic Test Results (PLEASE ATTACH A COPY OF MOST RECENT BLOOD TESTS, LAB RESULTS, AND RADIOGRAPHIC FINDINGS): upload below or email to: info@lakecountyvet.com

File Upload

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Treatments & Medications Administered (list ALL drugs prescribed, including dosage and duration)

*Please Instruct Pet Owners to Continue to Give all Medications as Previously Prescribed and have diabetic patients bring insulin the day of the procedure*

Doctor:
Grace Brown, DVM

Periodontics, Oral Surgery, Orthodontics, Endodontics, Crowns, Restoratives & Intraoral Dental Radiography

Office Location
Two Harbors Clinic: 557 Scenic Drive, Two Harbors MN 55616
Grand Marais Clinic: 4 Gene's Way, Grand Marais, MN 55604
Email: info@lakecountyvet.com