Grooming Spa Application
To be completed prior to your pet receiving grooming services
Pet Owner's Information
Name
*
First Name
Last Name
Preferred phone number
*
-
Area Code
Phone Number
Alternate phone number
*
-
Area Code
Phone Number
Third number optional
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your email address
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact number
*
-
Area Code
Phone Number
Pet Information
First Name
*
First Name
Is your pet:
*
Dog
Cat
Is your pet:
*
Male
Female
Is your pet:
*
Neutered/Spayed
Intact
Breed
*
Color
*
Approximate Weight
*
Date of Birth
*
-
Month
-
Day
Year
Date
Health Issues or Concerns
Second Pet?
First Name
Is your 2nd pet:
Dog
Cat
Is your 2nd pet:
Male
Female
Is your 2nd pet:
Neutered
Spayed
Breed
Color
Approximate Weight
Date of Birth
-
Month
-
Day
Year
Date
Health Issues or Concerns
A Third Pet?
First Name
Is your 3rd pet:
Dog
Cat
Is your 3rd pet:
Male
Female
Is your 3rd pet:
Neutered
Spayed
Breed
Color
Approximate Weight
Date of Birth
-
Month
-
Day
Year
Date
Health Issues or Concerns
Your Vet's Information
Clinic Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
How did you hear about our Grooming Spa?
*
Advances in Animal Behavior
Animal Welfare
Black Dog K9
Chicagoland Tails
Drive By
Expo
Flyer
Friend
Internet search
Messenger news
Newsaper
Southtown Economist
Veterinarian
Yellow Pages
other
If referred by a friend, may we please have a name?
Service Authorization/Grooming Releases
We realize that your pet may not fall into any of the following categories at this time. We do require that you check each box to acknowledge your understanding of each of these conditions for future use:
Special Conditions Pet: I am aware that my pet has a special condition, specified below, and that the process of grooming maybe stressful, which may cause known symptoms such as arthritis, bone, joint or surgical sites to become active or inflamed, or become active or inflamed, and unknown conditions such as heart, kidney or liver disorders to become active and can result in illness, seizures, or the death of my pet. I agree to not hold PHPR responsible for possible reactions to grooming.
*
Agree
My pet's special condition is:
Emergency: In the event of a medical emergency I authorize PHPR to seek medical attention for my pet. I have read and understand the conditions above. I will not hold PHPR responsible for any pre-existing health problems my pet might have.
*
Agree
If necessary, do you authorize our trained staff to perform necessary emergency CPR, rescue and/or first aid procedures to your pet?
*
Yes
No
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: