Serenity Pool Therapy Reservation & Client Waiver

Serenity Pool Therapy Reservation & Client Waiver

All clients/ pets new to Graced Kennel & Dog Psychology must register an account and submit vaccine records to online prior to submitting this form.Submit one request per dog—your appointment isn’t confirmed until Graced Kennel reviews availability and contacts you to confirm details. New clients register for an account by going to https://gracedkennel.mykcapp.com/olr/preregister prior to submiting a request
Client Information
Owner Full Legal Name

First NameMiddle NameLast Name
Email
example@example.com
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method

Other
Reservation Request
Appointment
Service Selection
Reservations are requests only until availability is reviewed and confirmed. Pricing, prerequisites, and appointment details will be provided by Graced Kennel.
Session Goal
First Visit?
Referral Source
Acknowledgment
Dog Information
Dog's Name
Breed or Mix
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age (Years)
Sex
Spayed/Neutered
Weight (lbs)
Veterinarian Name
Veterinarian Clinic
Veterinarian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Vaccinations: Please note all vaccines must be current at least 10 before appointment and be uploaded to your client portal to be verified.
Rabies Vaccination Status
Rabies Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DHPP Vaccination Status
DHPP Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Bordetella Vaccination Status
Bordetella Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Medications or Supplements
Allergies
Medical Diagnoses
Recent Surgery or Injury
Pain or Mobility Limitations
Seizures or neurological conditions
Heart or respiratory concerns
Infection, open wounds, or contagious exposure
Swimming experience or fear of water
Bite history, aggression, reactivity, or resource guarding
Handling sensitivities or muzzle use
Other notes about your dog
Any Other Health or Behavior Concerns Staff Should Know
Confirmation of Accurate Information and Fitness for Participation
Human Participant Safety
Show this section only when Trainer/Dog/Owner pool session is selected.
Participant name
Swimming ability
Medical or mobility concerns
Emergency needs or accommodations
Acknowledge pool safety requirements
Participant safety acknowledgment signature
Only visible for Trainer/Dog/Owner involved pool sessions.
Waiver and release summary: participation is voluntary; you accept known and unknown risks; to the fullest extent allowed by Georgia law, the listed parties are released and held harmless from claims arising from ordinary negligence or inherent risks, except where gross negligence or intentional misconduct cannot be waived; you agree to indemnify for claims caused by you, your guests, family, or dog; you are responsible for dog-caused damage; minors and guests remain your responsibility; and this agreement applies to future Serenity Pool/Treadmill visits until revoked in writing, with a duty to disclose material changes before each visit.
Media permission
Authorize basic first aid and emergency veterinary treatment if you cannot be reached
If emergency care is needed and you cannot be reached, you agree to be responsible for related costs.
Rules and Informed Consent
Safety and supervision agreement
Disclosure of health and behavior information
Leash and control requirements
Staff authority to modify or end sessions
Nature of therapy and no guarantee
Assumption of risks
Instruction compliance acknowledgment
Emergency Authorization
Authorization Statement
Preferred Emergency Veterinary Hospital
Maximum Authorized Amount
Final Signatures
I have read, understand, and voluntarily agree
Typed legal name

First NameMiddle NameLast Name
Electronic signature
Signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Serenity Pool Therapy Reservation & Client Waiver

Client Information

Reservation Request

Dog Information

Vaccinations: Please note all vaccines must be current at least 10 before appointment and be uploaded to your client portal to be verified.

Human Participant Safety

Rules and Informed Consent

Emergency Authorization

Final Signatures