8470 Main Street
harrishill@buffaloveterinarygroup.com
www.harrishillanimalhospital.com
(716) 634-1000
Owner Information:
Owner Name
*
First Name
Last Name
Cell Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Preferred method of contact?
*
Please Select
Cell Phone
Email
Pet Information:
Pet Name:
*
Name
Pet Breed/Color:
*
Breed
Color
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Check Here if Date of Birth is estimated:
Estimated
Sex:
*
Male
Female
Is your pet spayed/neutered?
*
Yes
No
Is your pet microchipped?
*
Yes
No
Health Policy
For your pet's health and for the health of others in our care, we require the following vaccines to be current for all dogs grooming at our facility: Rabies, DHPP & Kennel Cough (Bordetella). Cats must be up-to-date on FVRCP and Rabies vaccines. If your pet has evidence of fleas or ticks, we will apply a preventative at your expense. Thank you for your help in keeping all of our animals safe and happy!
Grooming Instructions/Requests:
Pick-Up Time:
The groomer will call when your pet is ready to be picked up.
Please notify me when my pet is ready to be picked up via:
*
Email
Phone
If you need your groom completed at a specific time, please indicate when:
There may be an additional charge to accommodate an owner's request.
Please list your pet's belongings, if any:
Social Media Release:
Within the context of promoting our business and pet health, we would like to use images, videos, and/or information about your pet on our social media sites. Do you wish your pet to participate on our social media sites?
*
Yes
No
Emergency Care:
In the event of an emergency while your pet is in our care, every attempt will be made to reach the owner or guardian. If unable to reach an owner or guardian, and your pet is in need of urgent or emergent care, our Doctors and staff will perform diagnostics, medical and/or surgical procedures or treatments to preserve the life or comfort of your pet. We do not guarantee a successful outcome.
In the event of an emergency:
*
Yes, please treat my pet with whatever is necessary.
Yes, please treat my pet up to a certain amount.
I decline all treatment, including life-saving measures.
Please indicate what amount:
Emergency Contact Name:
*
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Payment policy
We accept cash, Mastercard/VISA/Discover/American Express and CareCredit. Payment is expected when services are rendered. We will gladly prepare you a written estimate of services prior to the treatment of your pet if you desire. I realize and understand that I am financially responsible for the care and treatment of my pet(s). I further agree that in the case of non-payment, a finance charge or interest fee and collection fees will apply.
Signature
Submit
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