Veterinarian Referral Form

Welcome, Referring Doctors!

Below is our referral form that we request you to submit if you have a case for Dr. Henry or Dr. Rice to review.

Click to download a printable version of this form (PDF). Fill it out, attach radiographs and/or pictures. and email them to us at info@midwestvetdental.com.

NOTE: Referral consult fee may apply.

  • Veterinarian Information

  • Client Information

  • Patient Information

  • Veterinarian's Notes & Information

  • File Uploads

  • If you have radiographs and/or photographs, please upload them here. (JPG, JPEG, PNG or PDF only; 5 MB limit per file.) If you have more than four (4) files to send, or if they are larger than 5 MB apiece, please email them directly to Midwest Veterinary Dental Services.
    Drop files here or
    Accepted file types: jpg, jpeg, png, pdf.
  • This field is for validation purposes and should be left unchanged.
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