MN Veterinary Dental Specialists

Patient Referral Information

Date of Referral

Referring office email for referral letter

example@example.com

Referring Doctor

Referring Hospital

Hospital Phone#

Owner's Name

Owner's Email

example@example.com

Owner's Home or Cell Phone

Owner's Street Address

City

State

Zip Code

Pet's Name

Date of next rabies or rabies exempt

Date of Birth

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: Dentistry@MNVDS.com

File Upload

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 K. Brown, DVM, DAVDC

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

Office Location
Two Harbors Clinic: 557 Scenic Drive, Two Harbors MN 55616
Email: Dentistry@MNVDS.com