Patient Drop Off Form (Grooming-by appt) Owners NamePet's NameBest PhoneAlternative PhoneReason for Visit: Grooming +Optional Services Nail Dremel $10 Teeth Brushing $8 Conditioner $5-$10 Special Shampoo $8-$12 Furminator Pampered Pooch $30 May we post your pet's photo on social media (i.e. Facebook, Instagram)? Yes No If necessary for grooming or medical care, do we have permission to sedate your pet? Yes No Are there any problems your pet might have of which we should be aware of?To effectively diagnose and treat many conditions, diagnostics such as x-rays, blood work, and other procedures may need to be performed. We will notify you by phone, ask for your permission to treat, and provide an estimate before undertaking these diagnostics. *I also authorize RHAH to dispense Capstar—a safe, proven flea control medication for an additional $9.00 (under 25lbs) or $10.00 (over 25lbs) if any evidence of a flea infestation is noted on my animal. **I understand that late arrival fees will range from $5 to $20, and no-show fees will range from $25 to $40, depending on the breed and amount of time missed. I agree to pay these charges as assessed. For further details, please ask. I HEREBY AUTHORIZE ROCKY HILL ANIMAL HOSPITAL, ITS DOCTORS, AND STAFF TO GIVE STANDARD AND ACCEPTED TREATMENT NECESSARY FOR THE WELL BEING OF MY PET. I AGREE TO BE RESPONSIBLE FOR ANY AND ALL COSTS INCURRED IN CONNECTION WITH ANY TREATMENT DURING A GROOMING VISIT. I UNDERSTAND ONLY THE MINIMUM DIAGNOSTICS AND/OR TREATMENT WILL BE ADMINISTERED TO MY PET UNTIL I CAN BE CONTACTED FOR DIRECT AUTHORIZATION.Type Full Name as Signature(Required)Date MM slash DD slash YYYY
