Dentition Submittal

Certified Canine Dentition Form

This form allows you to submit dentition data for your canine.
Who is the primary contact for this submission?

Primary contact for the canine being submitted.
Primary Contact Name

PrefixFirst NameLast NameSuffix
Primary Contact Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email
example@example.com

Who is the veterinarian performing this dental exam?

Identification and contact information for the veterinarian performing this exam.
Veterinarian Name

PrefixFirst NameLast NameSuffix
Veterinary Clinic Name and Address

Name of Clinic

Street Address

CityState / Province

Postal / Zip Code
Veterinary Clinic Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Veterinary Clinic Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Veterinary Clinic Contact Email
example@example.com

Does primary contact agree to publish results of dentition assessment in the searchable database for CCDR?

Other
Primary Contact Signature

I verify that the information in this form is correct and accurate to the best of my knowledge.

Dentition Submittal and Registration

$25.00 Quantity

Total

Verification of Identity

Examining veterinarian: please verify identification of dog.
Identification of Dog
Microchip Number

Certified Canine Dentition Form