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
Patient Information
Spayed or Neutered
New Client
Referring Veterinarian Information
Would You Like to Speak with Dr. Gleason on the Phone?
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.