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) If none, please write "none".*

*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