Groves VC - Grooming Registration Form

1
Owner’s Information
Last Name
First Name
Spouse
Home Phone#
Cell Phone#
E-mail
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Patient Health History
Pet Name
Dog
Cat
Species
Male
Female
Sex
Yes
No
Spayed/Neutered
Breed
Color
Age (Birth Date)
4
Veterinarian
Phone Number
5
Please list previous surgical procedures
6
Please list any medical conditions
7
Please list any allergies
8
What is your pets dental care routine?
Brush
Rinse
Water Additive
Dental Treats
9
How often does your pet groomed?
10
Please initial each following paragraph. Thank you.
11
Health or Medical Problems - Occasionally, grooming can expose a hidden medical problem or aggravate a current one. This can occur during or after grooming. All medical expenses for veterinary care will be paid by the pet's owner.
Owner's Initials
12
Accidents - Although accidents are very rare, there is a risk when dealing with animals. Grooming equipment is sharp, and although we use extreme caution and care in all situations, possible problems could occur including cuts, nicks, scratches, etc. Your pet’s safety and comfort is our number one priority. In the event an accident does occur, you will be notified of the accident. If Sandy feels it is serious,one of our on-site veterinarians will provide immediate veterinary care at your expense.
Owner's Initials
13
Veterinarian Authorization - Medical Emergencies This release gives Groves Veterinary Clinic authorization to treat your pet in the case of any medical emergencies while in the care of our grooming salon.
Owner's Initials
14
Fleas/Ticks - We are a flea and tick free salon. If your pet has fleas or ticks, he/she will be given a 24-hour Capstar and a medicated bath at your expense. If you do not want them to receive one, you can reschedule your appointment after the problem is taken care of by you.
Owner's Initials
15
Vaccinations - For the welfare of every guest in our salon, we require that your dog has a current RABIES, DISTEMPER and KENNEL COUGH/BORDETELLA vaccination and your cat has a current RABIES and FVRCP vaccination. By signing this form, owners/guardian verifies their pet is current with the required vaccines and proof shall be provided prior to any grooming service. IT IS YOUR RESPONSIBILITY TO KEEP TRACK OF YOUR PETS VACCINATION RENEWAL DATES.
Owner's Initials
16
Bordetella Vaccination - Kennel cough (similar to a human cold) is a respiratory condition caused by a variety of viruses and bacteria often spread by direct contact with dogs. At Sandy’s Pet Boutique, we HIGHLY recommend that your dog be vaccinated every six months against kennel cough/Bordetella. Keeping your dog vaccinated every six months will help to prevent the spread of kennel cough and/or diminish the severity of infection in your pet. If a pet should become infected, all treatment and costs associated shall be the pet owner’s responsibility
Owner's Initials
17
Dangerous or Aggressive Animals - In the event that your pet is too stressed or becomes dangerous to groom, Groves Veterinary Clinic has the right to refuse grooming services, stop grooming services, or cancel grooming services at any time before, during, or after grooming and the client will be charged a grooming fee (for what was done up until that point).
Owner's Initials
18
Matted Coats - Animals with severely matted coats require extra attention. Mats in an animal’s coat grow tight, and can ultimately damage and tear the animal's skin, which provides a breeding ground for parasite infestations. Mats can be very difficult to remove, and may require the pet to be shaved. Removing a heavily matted coat can cause nicks, cuts or abrasions due to skin growths trapped in the mats. Heavy matting can also trap moisture and urine near the pet's skin allowing mold, fungus or bacteria to grow, producing skin irritations that existed prior to the grooming process. After-effects of mat removal procedures can include itchiness, skin redness, self-inflicted irritations or abrasions and failure of the hair to regrow. In some cases, pets may also exhibit brief behavioral changes. Prevention is the best defense by scheduling regular grooming appointments, every 4-8 weeks. If your pet needs to be shaved to remove matting, by signing below, you acknowledge that you agree to this procedure, and any risk. There will be an additional charge for this process: it is time consuming, and causes extra wear and tear on grooming equipment.
Owner's Initials
19
Senior Pets - Grooming procedures can sometimes be stressful, especially for senior pets or pets with health problems, and can expose hidden medical problems or aggravate a current condition(s) during or after the groom. Senior pets and pets with health problems have a greater chance of injury. In the best interest of your pet this agreement will allow Groves Veterinary Clinic to obtain immediate veterinary treatment for your pet from one of our on-site veterinarians should it be deemed necessary. It is agreed that all expenses for veterinary care will be covered by the pet’s owner upon signing this agreement.
Owner's Initials
20
Returned Checks - For each returned check, a fee of $30.00 will be assessed.

Photographs
This release form authorizes Groves Veterinary Clinic to take photos of your pet for client file and for advertising. All photos taken are the property of Groves Veterinary Clinic.

I have reviewed this agreement and I affirm that I am the legal owner of the pet for which services are being rendered. The owners/guardians agrees to hold Groves Veterinary Clinic, it's owners, employees, officers, etc. harmless from any damages or losses arising from any condition or ailment of the pet, either known or unknown. It is understood this clause applies to any and all pets receiving any service(s). I authorize this signed agreement to be valid approval for future grooming services, permitting Groves Veterinary Clinic to accept telephone reservations for service without additional signed agreements. I understand that pricing is subject to change.
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Print Name of Owner* This field is required.
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Signature of Owner* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
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