Survey - Angell Dentistry Referral Form

REFERRING VETERINARIAN INFORMATION

1.

Please provide your information.

*

Name:

Title	First Required	Last Required

*

Email: Required

*2.

Question - Required - Referring Veterinarian/Clinic:

(Maximum response 255 chars, approx. 5 rows of text)

*3.

Question - Required - Referring Veterinarian/Clinic Phone:

4.

Question - Not Required - Referring Veterinarian/Clinic Fax:

REFERRAL INFORMATION

5.

Question - Not Required - Please check all that apply.

	Schedule Appointment
	Emergency - If this is an emergency, is it one of the following?
	Any type of jaw fracture
	Teeth that have been fractured within the past 48 hours, and the owner's intent is to save the tooth/teeth via a vital pulpotomy procedure
	Tooth avulsion or luxation injuries
	Traumatic malocclusion/orthodontic cases

6.

Question - Not Required - Time/Date of Appointment (if applicable):

*7.

Question - Required - Would you like us to call your client to schedule an appointment?

*8.

Question - Required - Should we advise your client to see the first available appointment or are you referring to a specific veterinarian?

First available

Specific doctor (please enter name below)

Ask client for their preference

9.

Question - Not Required - If you selected "specific doctor" above, please enter the name of the doctor to whom you are referring.

CLIENT INFORMATION

*10.

Question - Required - Client's Name:

PATIENT INFORMATION

*11.

Question - Required - Client Phone Number:

*12.

Question - Required - Pet's Name:

13.

Question - Not Required - Species/Breed:

14.

Question - Not Required - Age:

15.

Question - Not Required - Sex:

16.

Question - Not Required - Has this pet been seen at AAMC before?

17.

Question - Not Required - Weight:

MEDICAL HISTORY

*18.

Question - Required - Differential Diagnosis/Problem for which pet is being referred:

(Maximum response 255 chars, approx. 5 rows of text)

19.

Question - Not Required - Is the patient being referred for specific diagnostic procedures or treatments? If so, please describe.

(Maximum response 255 chars, approx. 5 rows of text)

20.

Question - Not Required - Client Concerns/Chief Complaint:

(Maximum response 255 chars, approx. 5 rows of text)

21.

Question - Not Required - Pertinent Medical History (symptoms, progression):

(Maximum response 255 chars, approx. 5 rows of text)

22.

Question - Not Required - Recent Vaccine History:

(Maximum response 255 chars, approx. 5 rows of text)

23.

Question - Not Required - Current Treatment:

(Maximum response 255 chars, approx. 5 rows of text)

24.

Question - Not Required - Current Medications:

(Maximum response 255 chars, approx. 5 rows of text)

25.

Question - Not Required - Additional Comments:

26.

Question - Not Required - Were radiographs taken?

27.

Question - Not Required - Were radiographs sent with client?

28.

Question - Not Required - Was lab work done?

29.

Question - Not Required - Were results sent with client?

30.

Question - Not Required - Were any other diagnostic tests done?

Please forward any related dental radiographs to dentistry@angell.org AND images@angell.org with the pet's name, client's name, and "Dentistry" in the subject line of the email.