Online Form

Veterinarian Referral Form

Submit the veterinarian referral form to refer a patient to Aggie Animal Dental Center for specialized dental and oral care.

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Veterinarian Referral Form

Read and fill out the veterinarian referral form accurately to refer a patient to Aggie Animal Dental Center for specialized dental care.

Veterinarian Referral Form

Name of referring veterinarian and hospital *

Your (referring veterinarian's) email address *

First and last name of client(s) *

First

Last

Client's phone number *

Would you like us to call the client? *

Yes
No, clients will call or email to schedule

Patient name *

Patient signalment (age, breed, and sex of patient) *

Reason for referral *

How urgently does this pet need to be seen? *

Urgently (within 10 days)
Semi-urgently (within 1 month)
Not urgently

(Please note that there is usually a 12-16 week wait for consultation appointments for chronic periodontal disease and fractured teeth. Urgent cases include malignant tumors or anorectic animals. Semi-urgent cases include acanthomatous ameloblastoma, plasmacytoma, or other non-metastatic but rapidly growing neoplasia)

Patient's other medical concerns *

for breed, additional

Patient ASA classification (if known)

ASA 1
ASA 2
ASA 3
ASA 4

Has patient had an anesthetized dental procedure at your clinic in the past? *

Yes, within the past year, and x-rays were obtained
Yes, within the past year; x-rays were not obtained
Yes, > 1 year ago, and x-rays were obtained
Yes, > 1 year ago; x-rays were not obtained
No

Medications pet is currently receiving (including antibiotics and/or pain medications prescribed for this issue)

Other notes for us

Upload patient records as a PDF here (see below for additional file uploads)

Click or drag a file to this area to upload.

Maximum file size allowed: 10MB

Upload a photo here if possible (or an additional PDF if needed)

Click or drag a file to this area to upload.

Maximum file size allowed: 10MB

Upload additional files here

Click or drag files to this area to upload. You can upload up to 5 files.

If you have >5 files to send, please email them to info@aggievetdentist.com

Request an Appointment

We are currently accepting new patients. Dr. May can see patients within a few weeks, and Dr. Lommer is currently booked out for 4-6 weeks. We have Urgent Care appointments available within days for patients with jaw fractures, tumors, or painful malocclusions.

Request Appointment

Have a Question?

Please complete our online form and a member of our team will get back to you as quickly as possible.

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Location

487 Miller Ave,
Mill Valley, CA 94941

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Contact Information

Phone: (415) 389-5917
Email: info@aggievetdentist.com

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Hours

Mon–Thurs: 7:30 AM – 5:00 PM
Fri, Sat, Sun: Closed

Name *

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Last

Email *

Phone

How can we help you? *

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