Veterinarian Referral Form | Midwest Veterinary Dental Services

Welcome, referring doctors!

Below is our referral form that we request you to submit if you have a case for Dr. Henry or Dr. Rice to review.

If you prefer, download a printable version of this form (PDF). Fill it out, attach radiographs and/or pictures. and email them to us at [email protected].

1Veterinarian Information

2Client Information

3Patient Information

4Veterinarian

5File Uploads

Veterinarian Information

Submitting Veterinarian's Name(Required)

First Last

Submitting Veterinarian's Country(Required)

Address(Required)

City State

Submitting Veterinarian's Email(Required)

Enter Email Confirm Email

Submitting Veterinarian's Phone Number(Required)

Client Information

Client's Name(Required)

First Last

Client's Phone Number(Required)

Patient Information

Patient's Name(Required)

Patient's Breed(Required)

Patient's Age(Required)

Patient's Sex(Required)

Male

Female

Veterinarian's Notes & Information

Presenting Complaint(Required)

External Exam(Required)

Oral Soft Tissue Findings(Required)

Periodontal Findings(Required)

Occlusion(Required)

Endodontic Findings(Required)

Any Additional Information:

File Uploads

Select files to upload (optional):

If you have radiographs and/or photographs, please upload them here. If you have more than four (4) files to send, or if they are larger than 5 MB apiece, please email them directly to Midwest Veterinary Dental Services.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB, Max. files: 4.

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Phone

This field is for validation purposes and should be left unchanged.

Welcome, referring doctors!

Veterinarian Information

Client Information

Patient Information

Veterinarian's Notes & Information

File Uploads

Clinic Location

Request an appointment

Apply for Care Credit

Affiliated Organization