Circle City Vets Dental Radiography Consulting Form

Welcome to Our Hospital

Dental Radiography Consulting Form

Please fill out the complete form so we can better help diagnose the problem
* Required field *

1.) * Veterinarian name: *
2.) * Veterinary Clinic: *
3.) * Phone number: *
4.) * Patient name: *
5.) * Owner's name: *
6.) * Email address: *
7.) Signalment & History:
8.) Physical exam findings:
Dental examination findings, please include the following: 9.) Character of gingiva including any recession:
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10.) Any abnormal probing depths
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11.) If any teeth have complicated (pulp exposure) or uncomplicated (no pulp exposure) fractures or wear
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12.) Signs of resorption (we recommend full mouth radiographs on all patients with signs of resorption)
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13.) Discolored teeth
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14.) Missing teeth
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15.) Dental crowding or malocclusions
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16.) Any pertinent cytology, histopathology or blood work
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17.) Current Therapy, Treatment, Medications:
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18.) If you have an image to include, browse your folders and add below. If additional images need to be sent, please send as a separate form. You will only be charged for one consultation.
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Verification:

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