Dental Referral Request

Dental Referral Request
The following form is to arrange booking for the RSPCA ACT dental program and must be filled out by a vet clinic.

Only clients who have no other way to pay for dentistry and have been declined VetPay qualify for the RSPCA dental program. The pet owner also needs to be receiving a Centrelink payment.

Pets with pre-existing health problems such as kidney failure or that need other procedures (such as xrays or ear infection treatment) performed with their dentistry cannot be assisted under this program.
Date*

MonthDayYear
Date
Referring Vet Clinic*
Has the client applied for Vetpay?*

YesNo (please do this first)
Vetpay reference number*
Pet's name*
Pet owner's name*

First NameLast Name
Email address of pet owner*
Phone number of pet owner*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Breed *
Pet's age/date of birth*
Pet's weight (approximate is fine)*
Dental grading (eg grade 3 dental disease)*
Please upload a copy of the patient history here

Browse Files

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