Grooming Release Form
Client ID:
Client Name:
Address:
Telephone:
Patient ID:
Date:_______________________
Name:
Species:
Breed:
Sex:
Color:
Birth Date:
Your pet is important to us and we care about your pet’s safety and well-being. We want to assure you that every effort will be
made to make your pet’s visit as pleasant as possible. To assist us with this, please provide the following information.
Due Dates of Current Vaccinations:
Distemper/Parvo/Corona ______________________ Feline Distemper__________________________________
Bordetella__________________________________ Feline Leukemia__________________________________
Rabies _________________________________ 1 year or 3 year
All animals must be current on rabies vaccination. All other vaccinations are recommended. If not, Ammon Veterinary Hospital
will perform a wellness exam and administer any necessary vaccinations at your expense. If your pet is not a patient at Ammon
Veterinary Hospital and has received vaccinations elsewhere, we would be happy to call your pet’s current veterinarian to update
our records.
Is your pet being treated for any medical conditions at this time? Yes_________ No _________
If yes, please explain:
Does your pet have any allergies, and would you like us to use an allergy shampoo on your pet?
Yes_________ No _________ If yes, please explain:
If your pet is severely tangled or matted, there may be an additional fee. Severe tangles or matting may also increase the risk of
injury.
I understand that my pet is severely tangled or matted and requires shaving. Please initial ______
I, ____________________________________, give the groomer at Ammon Veterinary Hospital permission to bathe and groom
my animal. I realize that grooming requires the use of scissors and other cutting instruments and that such use may result in injury
if the animal moves suddenly, or if the animal is severely tangled or matted. I understand that the doctors, Ammon Veterinary
Hospital, groomer and staff will not be held responsible for injuries while in the course of normal routine care. In the case of
injury due to movement of my animal, or complications due to matting, I authorize_______do not authorize_______ immediate
veterinary care of my pet.
__________________________________________________________ ___________________
Signature of Owner or Agent
Date
_____I would like this form to be effective for 1 year from date of signature.
_____I would like this form to be effective only for the date of signature.
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Anesthesia for Grooming
In some cases, the stress caused by grooming is too much for an animal to handle. Additionally, some animals may be too fearful
or aggressive to be safely handled by the groomer. In these cases, to proceed with grooming, anesthesia may be required.
I understand that some risks always exist with anesthesia and that I am encouraged to discuss any concerns I have about those
risks with the attending veterinarian before grooming is initiated. My signature on this form indicates that any questions I have
regarding the following issues have been answered to my satisfaction:
* The reasonable medical treatment options for my pet
* Sufficient details of the procedures to understand what will be performed
* How fully my pet will recover and how long it will take
* The most common and serious complications
* The length and type of follow-up care and home restraint required
* The estimate of the fees for all services
* Any necessary payment arrangements.
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no
guarantee or warranty has been made regarding the results that may be achieved. I agree to provide payment via cash, credit card,
debit card, or Care Credit at the time my pet is discharged from the hospital. Should unexpected life-saving emergency care be
required and the hospital staff is unable to reach me, the staff has______/does not have______ (check one) my permission to
provide such treatment and I agree to pay for such services.
Additional Options for Anesthetic Procedures
Please note that if your pet is 7 years of age or older, or your pet will be undergoing abdominal, thoracic or orthopedic surgery,
the following options are required.
Blood Work
The well-being of your pet is our top priority. Prior to putting your pet under anesthesia we will perform a physical
exam. However, many conditions, including disorders of the liver, kidneys, or blood may not be detected unless blood work is
performed. [For more information regarding what we are looking for on your pet's blood work, click here.] For this reason,
we recommend that pre-anesthetic blood work be completed to confirm that your pet is in a low risk category by ruling out preexisting internal problems that could lead to complications. If there is an abnormal result in this screening, other options for
further diagnostics will be discussed with you. In pets 7 years of age and older we require pre-anesthetic blood work prior to any
anesthetic procedure.
The cost of the pre-anesthetic blood work is $69.50 (in addition to anesthesia cost).
__ Yes, I want my pet to have pre-anesthetic blood work.
__ No, I do not want my pet to have pre-anesthetic blood work.
__ Required for this procedure.
_______TO BE SIGNED AT TIME OF CHECK-IN___________________
Signature of Owner or Agent
Date
Phone number(s) at which owner or agent can be reached today and/or tomorrow.
_____________________________________________________________________
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1290 S. Ammon Road, Idaho Falls, ID 83406 (208) 552-9825 (208) 552-3168 fax
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ammonvet.com