Please provide following contact information:

Name

Street Address

City

State

Zip

Work Phone

Home Phone

Email

Today's Date

Please provide your emergency contact name:

Emergency phone number?

Pet's name

Pet's breed

Pet's birthdate (mm/dd/yyyy)

Sex: Male Female

Choose one of the following options: Spayed Nuetered

Vet's Name


Vet's Phone

Date of last check up

Any problems, or areas of concern that you are aware of, i.e.: bad hips, ear/skin infections?

Has your pet ever shown any signs of aggression, if so, to what extent, and what were the circumstances?

Dirty Dog Days will not be held responsible for clipper burn and/or minor nicks resulting from the grooming of matted, neglected coats or for irritation caused by removing coat from pets possessing mild to severe skin allergy, nor will we be held responsible for stressful effects grooming may have upon the pet , such as seizures, strokes, heart attack, coma and/or death. The owner will disclose all information related to the overall health of the pet. The owner will be responsible for maintaining yearly shots and check-ups with their veterinarian. The owner shall inform any employees of Dirty Dog Days of any behavior and/or aggression issue the pet may have. In the event that the pet should bite any employee of Dirty Dog Days , the owner will be held liable for all doctor and hospital bills.

The owner will notify Dirty Dog Days of any claims for medical attention given as a result of alleged negligence on our part within 24 hours. Failure to give notice within such time period relieves Dirty Dog Days from any liability or obligation to the owner. The owner agrees to give a 72 hour cancellation notice of any appointment, failure to do so will result in a $40.00 missed appointment fee. There will be a $30.00 fee for all returned checks. Dirty Dog Days accepts cash and checks only.

By submitting this form, I certify that I am the owner/agent of animal(s) listed on information card and agree to be bound by this agreement.