First Name*

    Last Name*

    Email*

    Phone*

    Street Address*

    City*
    State*
    Zip*

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    Dog's Name*

    Male or Female*
    Male
    Female

    Spayed/Neutered?*
    PLEASE NOTE: Our clinic will not accept intact (not spayed/neutered) animals.
    Yes
    No

    Pet's Approximate Age* (in years)

    Pet's Approximate Weight* (in pounds)


    PLEASE NOTE: This service is available for dogs up to 30 pounds. (We may be able to accommodate dogs 30 to 50 pounds, but there are additional fees and requirements).

    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

    Does your dog have ANY other health concerns that we should know about? We all want your dog to successfully have surgery. For best possible outcomes, please let us know of ANY medical concerns such as kidney issues, heart murmurs/issues, seizures, infections, etc.*

    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!