Grooming Request | Cornerstone Animal Hospital

Name*

First Last

Phone Number*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Who may we thank for recommending our hospital to you?

How did you hear about us?

Pet Information**

Name	Type of pet (Canine/Feline)	Sex	Neutered/ Spayed	Breed	Age/year /month	Weight

Are your pets vaccines current?*

Yes
No
Never Vaccinated

Are your pets current on Flea prevention?*

Yes
No
Never Used

Appointment 1st(Choice)*

Time*

:

Appointment 2nd(Choice)

Time

:

My pet has the medical condition

Other conditions requiring veterinary attention

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

Other

Grooming Services

Bath only
Shave Down
Anal Glands expression
Clean Ears
Toe nail trim (TNT)
Hair trimming only

Desired Coat Length in Inches

I 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 Hospital I 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 agent

Date

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