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
Submitting Veterinarian's Name*
First Last
Submitting Veterinarian's Email*
Enter Email Confirm Email
Submitting Veterinarian's Country*
Submitting Veterinarian's City*
Submitting Veterinarian's State*
Submitting Veterinarian's Phone Number*
Submitting Veterinarian's Phone Number*
Client Information
Client's Name*
First Last
Client's Phone Number*
Patient Information
Patient's Name*
Patient's Breed*
Patient's Age*
Patient's Sex*
- Male
- Female
Veterinarian's Notes & Information
Presenting Complaint*
External Exam*
Oral Soft Tissue Findings*
Periodontal Findings*
Occlusion*
Endodontic Findings*
Any Additional Information:
File Uploads
Select files to upload:
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.
Comments
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Equine Services

Routine Dentistry
Restorations & Endodontics
Oral Surgery
Periodontics
Young Horse Dentistry

A good, thorough dental exam should be done at least once a year for most adult horses. In some horses, we recommend dental work to be done every six months.

Horses can have decay happen to their teeth, similar to people, which can cause cavities or exposure to the vital portion of the tooth, the pulp, which may potentially lead to the fracturing of a tooth and/or other problems.

Midwest Equine Services offers both basic and advanced extraction services, as well as performing sinus surgeries on those horses that need them.

Horses can get periodontal disease (gum disease). This may occur for various reasons. Equine teeth are unique in that they continuously erupt into the mouth.

Dental examination should begin at birth. When your foal receives his first wellness examination at birth, a brief dental examination should be performed at that time.

Name*
First Last
Email*
Enter Email Confirm Email
Country*
Your city*
State*
Phone*
Phone*
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Name
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Welcome, Referring Doctors!

NOTE: Referral consult fee may apply.

Veterinarian Information

Client Information

Patient Information

Veterinarian's Notes & Information

File Uploads