First Name*

Last Name*

Email*

Phone Number* (please use dashes! cell preferred)

Street Address*

City*
State*
Zip*

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Pet's Name*

Canine or Feline*
Feline
Canine

If Feline, is your cat negative for FeLV (Feline Leukemia Virus)?*
Negative
Positive
Unknown / Not tested

If Feline, is your cat negative for FIV (feline Immunodeficiency Virus)?*
Negative
Positive
Unknown / Not tested

Male or Female*
Male
Female

Spayed/Neutered?*
Yes
No

Pet's Age* (in years)

Pet's Approximate Weight* (in pounds)

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

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

Bad breath,Drooling,Hiding,
Pain eating,Not eating,Batting at mouth,
Red gums,Bleeding gums,Vet recommendation,
Tartar,Broken tooth,Loose tooth,

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

Estimates/Quotes you have received elsewhere?
(you can 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!