Spa Day Consent Form – Chester Valley Veterinary Hospital

Owner's name *

First

Last

Email *

Primary phone *

Secondary phone

Has your pet been seen previously by a veterinarian? *

Yes
No

Please have your previous veterinarian send all previous medical history for your pet via email (healthypetalaska1@gmail.com) or fax (907-337-4311) PRIOR to your scheduled appointment. Failure to have previous records prior to a scheduled appointment can result in both a delay in care and a medical records retrieval fee.

Pet's name *

Do you think it is possible that your pet will bite or injure you while in the vet clinic? Please let us know so we can have staff prepared to help. *

Yes
No

Do you feel that your pet may bite or injure a staff member while at the vet? Please let us know so that we can keep all staff and animals safe. *

Yes
No

Do you have any physical limitations that would cause you to be unable to handle your pet inside the clinic? Please let us know so we can have staff prepared to help. *

Yes
No

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

I am the owner of the animal named above, and have the authority to execute this consent and give Chester Valley Veterinary Hospital permission to bathe and groom my animal. *

I have read and authorize

The fees associated with these services have been explained to me, and I agree to pay such fees at the time these services are completed. *

I have read and agree

I understand, if not agreed upon before hand, that if sedation is needed Chester Valley Veterinary Hospital will attempt to contact me with an estimate before proceeding. If they are unable to reach me that they will not proceed with grooming. *

I have read and understand

I understand that my pet must be up to date on their rabies vaccination before grooming and that a vaccination exam will be charged for any animals requiring a vaccine during their grooming appointment. *

I have read and understand

I realize that grooming can require the use of scissors and other cutting instruments, and that the use of such can result in injury if the animal being groomed moves suddenly. In such an event I will not hold the groomer or Chester Valley Veterinary Hospital responsible for any injuries that occur during grooming. *

I have read, understand, and agree

I am aware that if my pet has a matt or multiple matts that cannot be brushed out, it/they will be cut out or shaved out as needed. This may result in an uneven look or bald spots and I will not hold the groomer or Chester Valley Veterinary Hospital responsible. *

I have read, understand, and agree

Acupuncture Authorization: Pet acupuncture can be used to treat a host of issues, from pain, appetite stimulant, GI concerns, URI concerns and even sedation and anxiety. Acupuncture is the process of carefully placing special needles at certain points on the body in order to stimulate the nerves and lymphatic systems, as well as create complex interactions with the fascia layer and release of different chemicals and hormones in the body. This results in reduced pain and inflammation, and increased nerve function. Some patients may be slightly sore after treatment. It is not uncommon to also be more sedate after a treatment. I approve/decline the use of simple acupuncture as deemed fit for my pet by Dr. Tobiason. *

Approve
Do Not Approve

If Approve, Please Initial Below: *

Do you have any other concerns in regards to your pet's health? *

Current medications and supplements

Current medications/herbal supplements

Contact Information for Today

Primary contact today (name) *

Primary phone today *

Any additional information you feel is important for us to know?

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Digital signature *

Date *

Please note: We will be closed on Wednesday, December 25th, in observance of Christmas and Wednesday, January 1st, in observance of New Years!

Current medications and supplements

Contact Information for Today