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?YesNoNever VaccinatedAre your pets current on Flea prevention?YesNoNever UsedAppointment 1st(Choice) Date Format: MM slash DD slash YYYY Time : HH MM AM PM Appointment 2nd(Choice) Date Format: MM slash DD slash YYYY Time : HH MM AM PM My pet has the medical conditionOther conditions requiring veterinary attentionI would like my pet to receive the following services:(at additional cost)Doctor ExamVaccinationsHeartwork TestFlea ProtectionAnnual Blood WorkUrinalysisX-rayOtherI 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 OtherGrooming ServicesBathClean EarsShave DownToe nail trim (TNT)Anal Glands expressionGrooming ServicesBathClean EarsShave DownToe nail trim (TNT)Anal Glands expressionGrooming ServicesBathClean EarsShave DownToe nail trim (TNT)Anal Glands expressionGrooming 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 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 agentDate Date Format: MM slash DD slash YYYY CAPTCHA
