Dental Referral Request

Dental Referral Request
The following form is to arrange booking for the RSPCA ACT dental program. You must have your pet assessed by a veterinarian and have been given a dental estimate.

Only clients who have no other way to pay for dentistry and have been declined VetPay qualify for the RSPCA dental program.

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.

There will be 1-2 months delay in booking your pet in for dentistry.
Date

Month Day Year
Date
Have you applied for Vetpay?

Yes No
Vetpay reference number
Pet's name
Pet owner's name

First Name Last Name
Email address of pet owner
Phone number of pet owner
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Breed
Pet's age/date of birth
Pet's weight (approximate is fine)
Do you give permission for us to request your pet's history from your regular veterinarian to be sent to the RSPCA?

Yes No Not applicable
Regular veterinary clinic name
If you are a referring vet clinic, please attach the veterinary history here or email it to actpetcrisis@gmail.com

Browse Files

Cancel of
Are you receiving financial payments from Centrelink?
Estimate of amount for dental treatment from your vet:
If using Centrepay you will need to pay at least $80 deposit on the day of your pet's procedure and at least $60 per fortnight from your Centrelink payment. Please type YES to confirm you understand this.
Do you consent to your pet's photo being used for social media (Instagram and Facebook)?

Yes No
Should be Empty: