Grooming Consent Form

First & Last Name of Pet Owner

Client Phone Number

Email

Pet Name

Grooming Location

Pembroke Vet
Sajo Farm Vet
Great Bridge Vet

1. Requested day of service. (1 of 2) Please provide 2 available dates. Sunday or holidays that we are closed. Grooming appointments are scheduled as day admits and drop-off is between 730am and 830am. Pick-up will be later in the afternoon. You will be called when ready for pick-up.

2. Requested day of service. (2 of 2)

Flea and Tick Treatment Consent Please read the following and TYPE YOUR INITIALS in the space provided stating you understand. Each pet will be flea and tick checked. If your pet has fleas or ticks, he/she will be given a one-time dose of Capstar and a monthly flea and tick treatment. **If we do not have an up-to-date doctor/client/patient relationship, a comprehensive physical examination will be performed and charged at the owner's expense.

Has there been any coughing, sneezing, or nasal discharge in the past 30 days?

Yes
No

Medical Services

Vaccinations For your pet's protection, in order to be groomed, your pet must be up to date on his/her Rabies, DA2PP/FVRCP, Canine Lepto, Canine Influenza, Canine Bordetella vaccine, and an intestinal parasite screen must be current. If any vaccinations are past due, your pet must be vaccinated before grooming for his/her protection. Vaccines administered will require an examination fee and will be added to your bill. If your pet has been vaccinated at another facility, we require proof of vaccination before they are dropped off. All animals left without proof of vaccination will be vaccinated at the owner's expense.

My pet is up to date with the above required vaccinations and intestinal parasite screen.
My pet was vaccinated against the above listed vaccinations elsewhere. I will be providing this certification.
I will schedule an appointment prior to grooming to have the services performed.
Other

Vaccinations - Other

Medical Services To Be Completed Please check any of the following desired Medical Services to be completed during your pet’s stay. All services with a "+" beside them will need you to complete a Health Assessment Form (https://forms.gle/XrB7amL76HfFGiuH9). This can be completed after your grooming form is submitted. Services with " * " will need more information.

No additional medical services needed at this time
Preventative Healthcare Visit with a doctor + *
Vaccination Initials or Boosters * + (Please note certain vaccines do have a doctor visit associated with them.)
Medical Progress with a doctor + *
External Parasite Prevention* (Simparica Canine, Bravecto Canine, Revolution Plus Feline)
Heartworm Prevention* (ProHeart 6 or 12 Month Injection Canine, Sentinel Spectrum Canine, Revolution Plus Feline)
Microchipping
Other

Medical Services To Be Completed - Other

Medical Services To Be Completed - Notes

Grooming Services

Grooming Services being requested: Bathing services include nail trim, anal gland expression (external), and ear cleaning.

Bath only
Bath and Haircut

Please describe in detail the type of haircut you are requesting:

Additional grooming services (optional) please check all that apply

Dematting
Nail Dremel
Medicated bath
Other

Additional grooming services - Other

Are there any special needs for the bathing of your pet? Specify special bathing needs or type N/A

Disclosure Information

Disclosure Acknowledgement Please read the following and TYPE YOUR INITIALS in the space provided stating you understand. This hospital is to use all reasonable precautions against injury, escape, or death of your pet and the hospital and staff will not be held liable for any problems that develop providing reasonable care, and precautions are followed. If medical treatment of your pet is needed, we will contact you via your contact information prior to treatment. I understand that any problem that develops with my pet while I'm absent will be treated as deemed best by the staff veterinarians and I assume full responsibility for the treatment expense involved.

Resuscitation Order In case of a life-threatening emergency, do you authorize CPR and life-saving measures for your pet? CPR and life-saving measures could start at a minimum of $300.00 to $500.00. Please note that we are NOT a 24-hour veterinary facility and your pet is left unattended outside of normal office hours

CPR Order: Yes, PERFORM life saving measures for my pet
DNR Order: No, DO NOT perform life saving measures for my pet.

Owner Release

Owner Release Acknowledgement Please read the following and TYPE YOUR FULL NAME in the space provided stating you understand. You are to use all reasonable precautions against injury, escape, or death of my pet. The clinic and staff will not be held liable for any problems that develop provided reasonable care and precautions are followed. I understand that any problem that develops with my pet while I'm absent will be treated as deemed best by the staff veterinarians and I assume full responsibility for the treatment expense involved. I agree to make complete payment at the time of discharge. I certify that my pet appears to be free of contagious disease and has not bitten anyone within the past ten days. I understand that if I fail to pick up my pet within ten days of notification to the above address, my pet will be considered abandoned and will be handled in accordance with Virginia state law, and that doing so does not relieve me of my financial obligations. I have read the above and I am in full agreement.