Client Form Dental Referral

Dental RSPCA Request
The following form is to arrange booking for the RSPCA ACT dental program and can be filled out by a pet owner.

Please note that the RSPCA can only accept referrals for URGENT dental procedures.

Pets with pre-existing health problems such as kidney failure or that need other procedures (such as xrays or ear infection treatment) performed with their dentistry cannot be assisted under this program.
Date*

MonthDayYear
Date
Yes - you can pay off the account via CentrepayNo - unfortunately you are not able to access this program
Pet's name*
Pet owner's name*

First NameLast Name
Email address of pet owner*
Phone number of pet owner*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Breed *
Pet's age/date of birth*
Pet's weight (approximate is fine)*
No - but I do have concerns about my petYes - and I am happy for you to request a vet history
Which vet clinic did your pet attend?
Does your pet have any other medical conditions?*
Is your pet currently on any medications besides flea, tick or worming? If so, what medications.*
I understand
Should be Empty:

Dental RSPCA Request