Name and contact number of referring DVM and Veterinary Clinic if applicable

Client name, phone number and email address

Patient name, birth year, sex, breed and location (town is sufficient)

Patient is referred for.. (eg: tooth extraction/sinus surgery/periodontal disease treatment)

Relevant patient history (eg: Fractured 308 was discovered after Patient presented with a swollen left mandible. Or, Patient has had a foul smelling left sided nasal discharge since July which improved with antibiotics but recurred.)

Please attach any radiographs, pictures or records available that would be beneficial for Dr Bishop to review