VDS Chadds Ford Referral Form

If you would like to refer a patient to VDS Chadds Ford for an advanced dental procedure, please fill out the form below. All fields marked with an * are required.

Date *

Client Information

Client Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone Number *

Email Address *

Pet's Name *

Species *

Breed *

Date of Birth (if known)

Age *

Patient History

Sex *MaleFemale

Spayed/Neutered? *YesNo

What symptoms have you observed at home? *

How long have the symptoms been present? *

Did the symptoms start suddenly? *

Are the symptoms *ProgressingStaying the SameImproving

Is your pet experiencing trouble eating and/or drinking? Please explain. *

Has your pet exhibited any of the following?

Excessive sneezingExcessive droolingDropping food from the mouthPawing at the mouthLip smackingNasal dischargeCheck all that apply.

Has your pet's appetite changed recently? *

What kind of diet (hard or soft) do you feed your pet? *

What types of snacks/treats do you feed your pet?

Does your pet chew on toys or bones? If so, what type and how often?

Do you have other pets at home? *YesNo

Please list the species and breeds of your other pets.

Do you provide any of the dental home care listed below? Please check all that apply.

Tooth brushingDental chews/treatsWater additiveOraVet

How often do you brush your pet's teeth? For how long?

What kind/brand of dental chews do you provide? For how long?

What brand of water additive do you use? For how long?

How often do you provide OraVet? For how long?

Has your pet ever received a professional dental cleaning under anesthesia? *YesNo

How often/number of times

When did your pet last receive a professional dental cleaning under anesthesia?

Has your pet had previous tooth extractions? *YesNo

Please list when your pet had previous tooth extractions and the clinic(s) this was performed at.

Has your pet ever received any other advanced dental procedures (root canal, etc.)? If yes, please list when and the clinic(s) this was performed at below.

Has your pet had any previous surgery other than spay or neuter? *YesNo

Please provide the details of your pet's past surgeries.

Does your pet have other medical problems we need to know about? Please explain.E.g. diabetes, heart disease, history of seizures, history of pancreatitis, etc.

Is your pet currently on any medications to treat the condition we are evaluating today? *YesNo

Please list the medications your pet is taking for this condition.

Have you noticed any improvement in the condition with these medications? Please explain.

Have medications previously been used for this condition that were not successful? Please explain.

Does your pet currently take any medications for UNRELATED problems? *YesNo

Please list ALL medications your pet currently takes for unrelated problems.

Does your pet have any medication reactions or food allergies? *YesNo

Please list the medication reactions or food allergies that your dog has.

Please list the name and contact information for ALL clinics/veterinarians that have treated your pet. Please include any out of town clinics, emergency clinics, or specialty practices such as a neurologist, cardiologist, dermatologist, etc. It is IMPERATIVE that we have this information in order to provide the best patient care possible. ****Please contact each of these clinics to have your pet's medical records (including ALL doctor's notes, radiograph reports, dental radiographs, oral charts, blood work, biopsy results, or any other pertinent information) sent to us by fax at (484) 778-4644 or via email at chaddsford@vdsvets.com.

How did you hear about us? *Referral from primary care veterinarianGoogle searchFacebookFriend/word of mouthOther

Primary care veterinarian's name *

Do you give VDS permission to use photos of your pet in our marketing materials (Social media, emails, etc.)? *Yes, I give permissionNo, I do not give permission

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