Grooming Request Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number*Email* Pet Information**NameType of pet (Canine/Feline)SexNeutered/ SpayedBreedAge/year /monthWeight Are your pets vaccines current?* Yes No Never Vaccinated Are your pets current on Flea prevention?* Yes No Never Used Appointment 1st(Choice)* MM slash DD slash YYYY Time* : Hours Minutes AMPM Appointment 2nd(Choice) MM slash DD slash YYYY Time : Hours Minutes AMPM My pet has the medical conditionOther conditions requiring veterinary attentionHiddenI would like my pet to receive the following services:(at additional cost) Doctor Exam Vaccinations Heartwork Test Flea Protection Annual Blood Work Urinalysis X-ray Other I would like my pet to receive the following services:(at additional cost) Doctor Exam Heartwork Test Annual Blood Work X-ray Vaccinations Flea Protection Urinalysis Other OtherHiddenGrooming Services Bath Clean Ears Shave Down Toe nail trim (TNT) Anal Glands expression HiddenGrooming Services Bath Clean Ears Shave Down Toe nail trim (TNT) Anal Glands expression HiddenGrooming Services Bath Clean Ears Shave Down Toe nail trim (TNT) Anal Glands expression Grooming Services Bath only Shave Down Anal Glands expression Clean Ears Toe nail trim (TNT) Hair trimming only Desired Coat Length in InchesI certify that I own or am the authorized agent for the above described pet, and I do hereby consent and authorize Cornerstone Animal Hospital and its staff to groom and care for my pet while it is under their care and supervision. I understand that I will be financially responsible to Cornerstone Animal Hospital for all charges related to the physical and medical care and services for this pet. I agree that all charges and fees will be paid in full at the time of discharge from Cornerstone Animal HospitalI hereby authorize Cornerstone Animal Hospital to groom, care for, and provide any medical treatment deemed necessary for the pet described above while being groomed.Signature of owner or agentDate MM slash DD slash YYYY CAPTCHA
