Owner/Responsible Party: ___________________________________________ Phone: _______________________
Arrival Date: __________________________ Departing Date (boarding clients only): ____________________
Emergency Contact_________________________________________________ Phone: _____________________
Pet Name(s):__________________________________________________________________________________
Breed(s):______________________________________________________________________________________
Color(s): ______________________________________________________ Age(s):__________________________
Is Your Dog Spayed/Neutered? YES or NO
Is Your Dog Up To Date On All Required Vaccinations? YES or NO
**Rabies, Bordetella, And Distemper ** (please verify by showing a copy of records to front desk)
Has Your Dog Ever Bitten Someone Or Shown Aggressive Tendencies? YES or NO
If Yes, Please Explain: ____________________________ _ ____________________________________________
Dues to certain circumstances a muzzle may be necessary to calm a dog down or to keep a dog from biting, if this is the case, do you agree to allow the groomer to muzzle your dog? YES or NO
(If NO, the groomer may not be able to finish your dog and your dog could go home half done, understanding you WILL still be charged for the full groom.)
Is Your Pet On A Monthly Flea Preventative? YES or NO
Is Your Pet Allergic To Anything? YES or NO ___________________________________________________________
Does Your Dog Have Any Pre-existing Medical Conditions including any skin conditions or moles/warts? If Yes, Please
Explain: _________________________________________________________________________________________
PLEASE CIRCLE ALL THAT APPLY TO THIS APPOINTMENT:
Would you like your pet to have (circle one): Bath & Brush Only or Bath & Hair Cut
If requesting a Bath & Hair Cut what is the desired length of hair?
☐ Leave long, slight trim ☐ Medium length ☐ Half Off ☐ summer cut (short) ☐ unsure, have groomer call
Would you like a typical cut for the breed? YES or NO
If NO, what kind of cut do you want, BE SPECIFIC !
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
EXTRAS: Check ALL that apply, even if says included, as the groomer will only do if checked.

Nail Trim (incl.)

Ear Cleaning (incl.)

Teeth Brushing
(incl.)



De-Matting $15+
Anal Glands (incl.)
Flea Shampoo $5



Nail Polish $10
Paw Bombs $6
Fur Butter $6
Do you have any special concerns or requests? YES or NO -Please be descriptive-

Blueberry Facial $5

Warren London Silk

Specialty Shampoo
$5
________________________________________________________________________________________________________
________________________________________________________________________________________________________

SAFETY
To ensure a safe environment for the groomer and your pet, please inform us prior to grooming if your dog has bitten someone or has aggressive tendencies. We reserve the right to stop the grooming process if the groomer feels that your pet’s behavior is compromising his or her safety or the safety of your pet. Prorated charges may apply. I have read and understand: _____ (initial)
MAT REMOVAL AND SKIN CONDITION
Removing a heavily matted coat included risks of nick, cuts or abrasions due to skin conditions such as warts, moles or skin folds trapped in the mats. Heavy matting can also trap moisture near the pet’s skin allowing mold, fungus or bacteria to grow, causing skin irritation that exist prior to the grooming process. After-effects of mat removal procedures can include itchiness, skin redness, self-inflicted irritations or abrasions and failure of the hair to re-grow. HRM is not responsible for the adverse effects of mat removal. I understand that I may need to apply sunscreen to my shaved pet until enough hair has grown back for protection. I also understand my pet may exhibit brief behavioral changes as a result of shaving. De-matting charges may apply. We do offer routine brushing appointments to help to prevent matting. Brush-out only charges will apply. I have read and understand: _____ (initial)
FLEA CONTROL
HRM is a flea-free environment. To remain flea-free, flea treatment will be administered at the first sign of fleas. I give HRM permission to administer this treatment and agree to pay any charges that may incur. Flea treatment will consist of a bath using a flea and tick shampoo. I have read and understand: _____ (initial)
SENIOR PETS AND PETS WITH PRIOR HEALTH CONDITIONS
Senior pets and pets with prior health conditions have a greater chance of injury; therefore, these pets will be groomed for cleanliness and comfort in styles that will not add to their stress. Furthermore, this means we will do the best we can, given the condition of your pet. I have read and understand: _____ (initial)
PAYMENT POLICY
I understand that I will pay a grooming fee for the base services I have requested for my pet and I will incur additional fees for any of the above ancillary services that I have requested. I further understand that if I do not pick up my pet by the close of business, I will incur boarding rates per the standard rate sheet. All grooming fees must be paid by Cash, Check, Visa, or MasterCard at the time services are rendered. Returned check due to insufficient funds will be subject to a $50 returned check fee.
Although the staff at Holly Ridge Manor closely monitors your pet, sometimes active play and roughhousing pose the possibility of injury. Additionally, certain illnesses and infections can be transmitted during boarding. Animals identified as being infectious will be isolated to the extent possible. Common injuries associated with boarding include, but are not limited to, bruises, lameness, abrasions, punctures, intestinal ailments (vomiting or diarrhea), coughing and skin irritations. These problems usually resolve with appropriate treatment.
If your pet develops any health problems, HRM will pursue treatment with one of the following: your veterinarian, Princess Anne
Veterinary Hospital, or an emergency treatment facility. Treatment may include, but is not limited to, injections, medication, and diagnostic testing. HRM will pay for the treatment when veterinary services are rendered, but the owner/responsible party is responsible for reimbursement at time of pick up.
The staff at HRM will make reasonable effort to contact the owner and/or emergency contacts should medical treatment be needed.
In the event that no contact is reached, please indicate your preference of action:
_____Please perform whatever services the doctor deems necessary for the best care of my pet until
Someone can be reached. Not to exceed: $_____________.
_____Do not administer any medical treatment until specific authorization is given .
I, the undersigned, so hereby certify that I am the owner (or duly authorized agent for the owner) of the animal aforementioned and authorize the doctors and staff at Princess Anne Veterinary Hospital or any other veterinary facility full and complete authority to provide medical care to promote the good health of my pet(s). I have read and understand HRM’s posted policies on emergency treatment, payment policy, return check fees, socialization risks and abandoned pets.
OWNER AND/OR RESPONSIBLE PARTY SIGNATURE_______________________ DATE__________ ____