Owner's Name *

First Name

Last Name

Cell Phone:

(###)

###

####

Text OK?

Yes

No

Home Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Caregiver

First Name

Last Name

Phone

(###)

###

####

Do you need a call to schedule a dental cleaning appointment?

Yes, please call me at the number above.

No, I already have an appointment scheduled.

Gender *

Male

Female

Spayed/Neutered *

Yes

No

Does your pet have a heart condition that you are aware of? *

Yes

No

Does your pet have loose teeth that you are aware of? *

Yes

No

Does your pet have a history of neck or back problems that may get aggravated during the procedure? *

Yes

No

I understand that the fee for this procedure is $200

YES

I understand that Laurie Monroe is a dental hygienist and will need about 30 - 45 minutes to clean and evaluate my dog's teeth while I wait in the lounge for her to be done.

Yes