Dental Radiology Consultation Form « Animal Hospital of Mt. Pocono News and Updates

Dental Radiology Consultation Form

*Required Fields

* Type of service Stat - Consult with Dr. Valese now. Fee $45.00 Service typically available M. Th. F. 9am-4pm Tu. 9am-7pm Sat 9am-12noon (varies). Call prior to submission to verify availability.
Routine - Dr. Valese will respond to your request within 1-3 business days. Free service. No need to call prior.

Doctor Information:

* Doctor Name

* Clinic Name

* Address

* Phone

Fax

* Email

For routine consult, list preferred method of contact. If telephone, list days and times available.

Patient Information:

* Client Name

* Patient Name

* Species

* Breed

* Sex M
M/N
F
F/S

* Age

* Weight

* Brief hx and clinical presentation

* Previous treatments - doses and durations

Image Information:

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Structure(s) of interest

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Structure(s) of interest

Upload Image 3

Structure(s) of interest

Upload Image 4

Structure(s) of interest

* Verify

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an appointment
(570) 839-8116

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