Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet's Name(Required)Name(Required) First Last What is your pet's heartworm prevention medication, when was the most recent dose given?(Required)What is your pet's flea & tick prevention medication, when was the most recent dose given?(Required)Is your pet on any additional medications or supplements on a regular basis?(Required) Yes No When is the last time your pet ate? (Time & Date)(Required)I understand that SWAH may need to contact me if there are any questions regarding the type of cut desired, special requests, or need for sedation. In addition, if other problems are found, we will need to call you to approve services or treatments needed. Grooming prices are for routine cuts only.(Required) I understand Standard Cut?(Required) Yes No Special InstructionsReference PhotoMax. file size: 128 MB.Vaccine Requirements: I understand that my pet must be current on vaccinations for canines: DHPP, Bordetella, and Rabies (administered by a licensed veterinarian) and felines: FVRCP and Rabies (administered by a licensed veterinarian) to stay in this facility. If my pet is overdue for these vaccines or if I fail to provide proof of vaccination, they will be administered at my expense.(Required) I understand Flea & Tick Policy: I understand that if external parasites are found on my pet that an appropriate treatment will be administered at my expense.(Required) I understand Consent for Treatment: I, the undersigned owner, or owner's agent, of the pet identified above, certify that I am at least 18 years of age, and thereby consent to the examination and treatment of my pet by the veterinarians and staff at SWAH and after consultation with me to prescribe medication for, treat, hospitalize, anesthetize my animal.(Required) I understand Grooming Policy: I, the undersigned owner, or owner's agent, of the pet identified above, understand there is a late fee applied to pets who are dropped off for grooming after the allotted drop off period (730am-8:15am). (Required) I understand I agree that I, or an agent of mine, will pick up my pet and pay for all accrued charges at the time my pet is discharged. If I fail to pick up my pet from SWAH within 5 days of receiving written or oral notification at the contact information on file that my pet is ready to be released, my pet will be considered abandoned, and SWAH may handle this abandonment in the best interest of the animal and the hospital. Payment is due at the time services are rendered. An estimate can be provided at your request, and you are encouraged to discuss all fees attendant to your pet's care.(Required) I agree Owner Phone Number(Required)Emergency Contact Phone Number(Required)Signature(Required) Δ
