Advanced Grooming 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

Medical History

See if your pet qualifies for "Sick/urgent care" walk ins or "Wellness" walk ins.

Excessive thirst? *

Yes
No

How long? *

Is your pet drooling excessively? *

Yes
No

How long? *

Is your pet lethargic? *

Yes
No

How long? *

Is your pet eating/drinking well? *

Yes
No

How long? *

Is your pet experiencing pain? *

Yes
No

How long? *

Does your pet have any wounds? *

Yes
No

Where? *

When did it happen? *

Is your pet panting excessively/experiencing labored breathing? *

Yes
No

How long? *

Is your pet experiencing labored breathing/wheezing? *

Yes
No

How long? *

Is your pet sneezing/coughing/hacking? *

Yes
No

How long? *

Is your pet experiencing any hair loss? *

Yes
No

Where? *

How long? *

Has your pet experienced weight gain/loss? *

Yes
No

How long? *

Does your pet have foul breath? *

Yes
No

How long? *

Is your pet experiencing difficulty urinating? *

Yes
No

How long? *

Is your pet experiencing excessive urination? *

Yes
No

How long? *

Have there been any changes in urine (color/odor)? *

Yes
No

How long? *

Is your CAT urinating outside of the litter box? *

Yes
No

How long? *

Is your DOG urinating inappropriately (having accidents inside the house)? *

Yes
No

How long? *

Does your pet have dirty/smelly ears? *

Yes
No

How long? *

Is your pet scratching their ears and/or shaking their head? *

Yes
No

How long? *

Is your pet experiencing eye discharge? *

Yes
No

How long? *

Is your pet squinting? *

Yes
No

How long? *

Is your pet vomiting (food/water/yellow bile)? *

Yes
No

How long? *

How many times per day/week/month *

Is your pet having diarrhea (liquid/soft/bloody)? *

Yes
No

How long? *

How many times per day/week/month (copy) *

Is your pet experiencing any lameness/limping? *

Yes
No

How long? *

Is your pet experiencing poor balance? *

Yes
No

How long? *

Is your pet experiencing inappropriate urination? *

Yes
No

How long? *

Are there any new or unusual lumps? *

Yes
No

Where? *

How long? *

You qualify for a "Wellness" walk in.

Rabies Questions

Is your pet's Rabies vaccination current? *

Yes
No

*Proof of current Rabies vaccination required at time of visit

Health Certificate

Are you being seen for a "Travel Certificate" or "Health Certificate" to drive across the border or to fly on a plane? *

Yes
No

Alaska physical address

Address Line 1

Address Line 2

City

State

Zip Code

Physical destination address

Address Line 1

Address Line 2

City

State

Zip Code

Transportation *

Flying
Driving
Ferry
Train

Travel purpose *

Vacationing
Moving

Are you traveling with your pet? *

Yes
No

Repeat your name *

First

Last

Your phone *

Person dropping pet off at airport name *

First

Last

Person dropping pet off at airport phone *

First

Last

Are you interested in anxiety medication today? *

Yes
No

Are you interested in flea/tick/heartworm preventatives today? *

Yes
No

Has your pet been to the Lower 48 before? *

Yes
No

Current medications and supplements

Current medications/herbal supplements

Advanced Grooming

We offer grooming services for pets who are unable to be groomed at regular facilities either due to their temperament or health. We here at Chester Valley Veterinary Hospital do attempt our best to make all groomed pets look their best but our primary goal is for the comfort and well-being of your pet.

Sedation is a wonderful method of helping your pet not experience pain or fear while we perform procedures that they need to keep them healthy. This not only helps them today, it also helps ease their fears during any future health events.

I understand that my pet needs to be sedated for grooming. I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. I have also been informed that there are certain risks and complications associated with any procedure of this type and that occasionally problems can occur due to pre-existing conditions that are not evident during routine histories and physical examinations. I understand that some risk always exists with anesthesia, even in apparently healthy animals. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical treatment to my pet in the event of unforeseen circumstances. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures. I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication. I understand the hospital support personnel will be used as deemed necessary by the veterinarian. *

I have read and understand.

I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital. *

I have read and understand.

Based on the health and temperment of my pet, I understand that my pet may require a change in the level of sedation necessary during their procedure. I hereby approve additional sedation for my pet as deemed necessary by the veterinarian. *

I have read and understand.

I understand that the staff at Chester Valley Veterinary Hospital are not professional groomers. Grooming services are offered for pets who are unable to be groomed at regular facilities either due to their temperament or health. Chester Valley will not guarantee a specific style of hair cut and I understand that the primary goal of this grooming is to help with the comfort and well-being of my pet. *

I have read and understand.

I am aware that if my pet has a mat or multiple mats 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 technician or Chester Valley Veterinary Hospital responsible. *

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.

Other

Recent emergency visits? Where was your pet seen? *

Primary contact today (name) *

Primary phone today *

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

Digital signature *

Date *