Request an Appointment

Please give us some information about yourself and the problem your pet is experiencing.
Fields in red are required information.
  Your first name:
Your last name:
Your Address:
City:
State/province:
Zip/postal code:
Your daytime phone number:
Your evening phone number:
Your email:
Your pet's name:

  What type of animal is your pet?  Other (Species) : 
Your pet's sex:  Breed: 
Is your pet neutered?  Body weight (in pounds): 
Your pet's color:  Age of your pet: 

Your pet's problems: Check all that apply.
 Bad breath
  Tartar
  Bleeding gums
  Gum recession
 Loose teeth
  Broken teeth
  Holes in teeth
  Discolored teeth
 Draining holes in jaw  Crooked teeth  Mismatching jaw lengths
 Swelling or mass in jaw     Swelling or mass on tongue     Swelling or mass on roof of mouth

Additional comments or problems:

Has your pet ever had dental work before?    Yes      No     
If so, what was done, and did it help?


Would you like to schedule an appointment with Dr. Colmery?    Yes      No     
If so, please select your first, second and third choices for an appointment time from the drop-down menus below.
First choice:  
   
Second choice:  
   
Third choice:  
   

After we receive your request for an appointment, a representative from Dr. Colmery's office will call you back within one business day to schedule a definitive appointment time.

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