Name: Veterinarian
Brand: Hambright Animal Hospital

Prefer to submit via fax?

Download Form PDF

Then submit the form, together with supporting documents via fax at 704-274-1570 or by email attachment to [email protected].

Client Information

Client's Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone

Patient Information

Pet's Name

Date of Birth

Species

Canine

Feline

Sex

Male

Female

Breed

Color

Spayed or Neutered

Yes

Date of Most Recent Lab Work and Dental X-rays (please send results with referral form)

New Client

Yes

Referring Veterinarian Information

Veterinarian Name

Name of Practice

Phone Number of Practice

Email of Practice

Reason for Referral

Would You Like to Speak with Dr. Gleason on the Phone?

Yes

Upload Most Recent Lab Work, Dental X-rays, and Vaccine History:

One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Please know a referral of your patient to us for dental care is something we appreciate and do not take for granted. Your client and patient will be treated with care and respect. No services other than dentistry will be performed on your patient unless you specifically request that we do so. Please trust that your client and patient will return to you for all non-dentistry services and may not become general practice clients of Hambright Animal Hospital.

Dental Referral Form

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