Grooming Intake Form

1

Owner Name* This field is required.

First Name

Last Name

2

Patient Name:* This field is required.

3

Make/Model/Color of the Vehicle You are Driving Today: * This field is required.

4

What is the best phone number to reach you TODAY to discuss your pet's care?* This field is required.

Area Code

Phone Number

5

Email

example@example.com

6

What is the best way for us to contact you today?* This field is required.

Phone

Text

Email

Other

7

We will do our best to accommodate your pick up schedule, please indicate if you need to pick up your pet by a specific time today:* This field is required.

8

Who are we authorized to release your pet to other than you?* This field is required.

9

Are you leaving any items with your pet (leash/collar/etc)? If so, please describe:* This field is required.

10

Date of most recent vaccinations:* This field is required.Use best estimate if exact date is unknown. Please note, a current rabies vaccination is required for our grooming patients. A rabies vaccine will be administered at your expense if you cannot provide records showing that this vaccine is current.

11

Date of most recent heartworm test:* This field is required.Use best estimate if exact date is unknown.

12

Is your pet receiving monthly heartworm prevention?* This field is required.

No

Yes

13

If YES, when was your last dose of heartworm prevention given?

14

If YES, what brand of heartworm prevention are you using?

15

Is your pet receiving monthly flea and tick prevention?* This field is required.

No

Yes

16

If YES, when was your last dose of flea and tick prevention given?

17

If YES, what brand of flea and tick medication are you using?

18

Does your pet have any known behavior problems or aggression issues (biting, separation anxiety, etc) that we should be aware of prior to grooming?* This field is required.An additional handling fee or sedation charge could be required. If sedation and anesthesia is declined, we may be unable to safely groom your pet.

19

Please indicate the grooming service to be performed today:* This field is required.

Bath and Brush Out

Nail Trim

Basic Grooming Package: Bath, Brush Out, Nail Trim, Ear Cleaning, Anal Sac Expression

Haircut + Basic Grooming Package

Shave Down + Basic Grooming Package

Scissor Cut + Basic Grooming Package

Feline Shave Down + Bath + Nail Trim

Other

20

Do you have any special grooming instructions or requests?* This field is required.

21

If your pet is found to be severely matted, additional charges may apply. If the groomer determines that combing out matts would overly stress your animal, please indicate how you would like us to proceed:* This field is required.

The groomer may clip the animal short all over

The groomer may clip the animal short ONLY where matted hair exists

The groomer MAY NOT cut any of the matted hair and should leave all matted hair as is

22

Occasionally we recommend sedation/anesthesia to facilitate grooming if a patient is overly stressed or aggressive. Please indicate how you would like to proceed if this happens:* This field is required.

I hereby consent and authorize sedation/anesthesia as needed to groom my animal. Any sedation/anesthesia is done under the supervision of a veterinarian. I understand this will warrant an additional charge.

I decline any sedation/anesthesia for my pet. I understand that in some cases this may limit what procedures the groomer and staff are able to perform on my animal.

23

Please indicate your consent for any additional procedures you are requesting today. Additional costs apply:If your pet requires a veterinary exam, please notify staff so we can schedule you a separate appointment.

Flea/Tick Treatment (required at your expense if your pet is found to have fleas or ticks)

Vaccinations

Intestinal De-worming

Heartworm Testing

Proheart 12 Injection (12 Month Heartworm Injection) - for dogs

Other

24

If requesting vaccinations, please indicate your pet's needs:

Rabies

DHLPP (Distemper/Parvo/Lepto/Parainfluenza) - dog only

Bordetella (Kennel Cough) - dog only

Canine Bivalent Influenza - dog only

Feline Leukemia and FVRCP (Calici/Rhinotracheitis/Chlamydia) - cat only

25

I, the undersigned owner or authorized agent of the above patient, hereby authorize the Doctors of the Animal Clinic of West Plains, Inc. to administer necessary treatment and perform medical procedures. I further understand that no guarantee of successful therapeutic or diagnostic outcome is made. I also assume financial responsibility for all charges incurred, and agree to pay all charges at the time of release, unless other arrangements have been made PRIOR to admission to the Clinic and PRIOR to treatment of the above described animal. Payment is accepted by cash, check, credit card, or CareCredit. We are not responsible for any acts of God that may occur while your pet is staying with us.

26

Signature of Owner/Agent* This field is required.

Clear

27

Date