Dental Referral Form

Prefer to submit via fax?
Simply print out the form on the right.  Then submit the form, together with supporting documents via fax at 704-274-1570 or by email attachment to

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Client Information


Patient Information

Date of Birth:
Spayed/Neutered? YesNo
Date of most recent lab work (please send results with referral form):

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? YesNo

Upload Most Recent Lab Work and Vaccine History:


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.