First Name*

Last Name*

Email*

Phone Number* (cell preferred) (XXX) XXX-XXXX

Cell Provider*
AT&T
Boost Mobile
Consumer Cellular
Cricket
MetroPCS
Sprint
T-Mobile
Verizon
Other

Can you send/receive texts using this number?*
Yes
No

Street Address*

City*
State*
Zip*

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Dog's Name*

Male or Female*
Male
Female

Spayed/Neutered?*
Yes
No

Pet's Approximate Age* (in years)

Pet's Approximate Weight* (in pounds)

Pet's Description* (color, pattern, breed)

Pet's Hair Length* (Short, Medium, Long)

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Do you need to rent a hard-sided carrier from us? ($20)*
Yes
No

Specific Symptoms
What alerted you to the dental problem in the first place? (check all that apply)*

Bad breath,Drooling,Hiding,
Pain eating,Low Appetite,Batting at mouth,
Red gums,Bleeding gums,Vet recommendation,
Tartar,Broken tooth,Loose tooth,

When was the last time your dog was seen by a vet? (enter as date xx/xx/xx)*

Do you have any recent labwork for your dog? (within the last 3-6 months?)*
Yes
No

Do you have any recent medical notes from a vet regarding your dog's current dental issues? (within the last 3 months?)*
Yes
No

Estimates/Quotes you have received elsewhere?
(please give a range from lowest estimate to highest estimate)*

It has come to our attention that our emails sometimes end up in people's spam folders. As soon as you click the submit button, an automated response email will be sent to the email address you submitted above. If you do not find this email within 5 minutes, please check your spam folder.

Be advised that the follow-up emails, including the most important one one asking you to confirm scheduled dates, will likely also end up in your spam folder. We require a response to this email to finalize and hold your appointment. Dates are assigned "first-come, first serve," and we are scheduling several weeks out. Please check your spam folder!