Dental Referral Request

If your pet needs a dental, or you are a referring vet clinic, please fill out the following details. The RSPCA will contact you to arrange treatment at the RSCPA Weston. If you have any additional enquiries, please contact petcrisisfund@gmail.com

Date

Referring Veterinary Clinic

Email address of pet owner

Phone number of owner

Pet owner's name

First Name Last Name

Pet's name

Pet's species

Pet's breed

Pet's age/date of birth

Pet's Gender

Are you receiving financial assistance? If so, what?

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Have you been given an estimate from your vet, if so, how much?

Has your pet had a dental treatment before?

If you know your pet's microchip number, please include it here.

If using Centrepay how much can you pay as a deposit (minimum is $80)?

If not using Centrepay, are you able to pay in full on the day (bill will be capped at $800)? If not, have you applied for VetPay?

Dentals are usually done on Thursdays at the RSPCA in Weston. What month would you ideally like to get your pet in for treatment.

Do you consent to your pet's photo being used for social media (Instagram and Facebook)?

Yes No