Randi Brannan, DVM
Fellow, Academy of Veterinary Dentistry
Diplomate, American Veterinary Dental College
Date: _________ Presenting complaint: ______________________________________________
Owner Information: __________________________________________________________________
Last Name First Name Spouse/Partner
____________________________________________________________________________________
Street Address City State Zip
(___)_________________(___)_________________(___)_________________(___)_______________
Home Phone Business Phone Cell/Pager Spouse Partner
___________________________________________________________________________________________
Workplace & Occupation Spouse/Partner Workplace & Occupation
E-mail Address: ________________________________________________________________________
Patient Information: _______________________Male Female Intact Neutered/Spayed Weight____lbs
Name
Canine Feline Other __________________________________________________________________________
Breed Color D.O.B Age
Any known allergic/drug reactions: ________________________________________________________________________
Patient Information: _______________________Male Female Intact Neutered/Spayed Weight____lbs
Name
Canine Feline Other __________________________________________________________________________
Breed Color D.O.B Age
Referred by: _______________________________________________________________________________________
Regular Veterinarian: _________________________________________________________________
First Name Last Name Clinic name
____________________________________________________________________________________
City State Zip Phone number
Hospital Policy: Animal Dental Clinic abides by a veterinary referral Code of Ethics. If your pet has been referred by your veterinarian for treatment by Dr. Brannan and requires medical attention unrelated to an oral condition, please contact your primary care veterinarian for further assistance.
809 SE Powell Boulevard
Portland, Oregon 97202
(503) 292-4533 Fax: (503) 445-4509