Randi Brannan,
DVM
Fellow,
Diplomate,
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.
(503) 292-4533 Fax: (503) 445-4509