Pet Information Form Please enable JavaScript in your browser to complete this form.Pet Owner InformationFull Name *FirstLastEmail *Address *Address Line 2Address Line 2City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington D.C.Zip *Contact InformationCell *Home Phone *Emergency Contact Number *Number of Pets *1234Pet Information (1)Pet Name *Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet Type *-- Please Select --DogCatOtherBreed *Gender *-- Please Select --MaleFemaleWeight (LBS.) *Color *Spayed/Neutered *-- Please Select --YESNOPlease check if your pet(s) has had the following preventative health care services within the last year:DistemperParvoInfluenza vaccineFlea and tick preventativePlease answer the following: Does your pet have any ongoing medical condition(s)? *-- Please Select --YESNOPlease explain: (Medical Conditions) *Is your pet currently receiving medication(s) *-- Please Select --YESNOPlease explain: (Medications) * Does your pet have Allergies/Skin allergies? *-- Please Select --YESNOPlease explain: (Allergies) *Please explain: (Mobility Issues) *Does your pet bite or bitten anyone in the past? *-- Please Select --YESNOPlease explain: (Reason For Bite) *Pet Information (2)Pet Name - 2nd Pet *Date of Birth - 2nd Pet *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet Type - 2nd Pet *-- Please Select --DogCatOtherBreed - 2nd Pet *Gender - 2nd Pet *-- Please Select --MaleFemaleWeight (LBS.) - 2nd Pet *Color - 2nd Pet *Spayed/Neutered - 2nd Pet *-- Please Select --YESNOPlease check if your pet(s) has had the following preventative health care services within the last year: - 2nd PetDistemperParvoInfluenza vaccineFlea and tick preventativePlease answer the following- 2nd Pet Does your pet have any ongoing medical condition(s)? - 2nd Pet *-- Please Select --YESNOPlease explain: (Medical Conditions) 2nd Pet *Is your pet currently receiving medication(s) - 2nd Pet *-- Please Select --YESNOPlease explain: (Medications) - 2nd Pet * Does your pet have Allergies/Skin allergies? - 2nd Pet *-- Please Select --YESNOPlease explain: (Allergies) - 2nd Pet *Does your pet have mobility issues? (2nd Pet) *-- Please Select --YESNOPlease explain: (Mobility Issues) - 2nd Pet *Does your pet bite or bitten anyone in the past? - 2nd Pet *-- Please Select --YESNOPlease explain: (Reason For Bite) - 2nd Pet *Pet Information (3)Pet Name - 3rd Pet *Date of Birth - 3rd Pet *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet Type- 3rd Pet *-- Please Select --DogCatOtherBreed - 3rd Pet *Gender - 3rd Pet *-- Please Select --MaleFemaleWeight (LBS.) - 3rd Pet *Color - 3rd Pet *Spayed/Neutered - 3rd Pet *-- Please Select --YESNOPlease check if your pet(s) has had the following preventative health care services within the last year: - 3rd Pet DistemperParvoInfluenza vaccineFlea and tick preventativePlease answer the following- 3rd Pet Does your pet have any ongoing medical condition(s)? - 3rd Pet *-- Please Select --YESNOPlease explain: (Medical Conditions) - 3rd Pet *Is your pet currently receiving medication(s)- 3rd Pet *-- Please Select --YESNOPlease explain: (Medications) - 3rd Pet * Does your pet have Allergies/Skin allergies? - 3rd Pet *-- Please Select --YESNOPlease explain: (Allergies) - 3rd Pet *Does your pet have mobility issues? - 3rd Pet *-- Please Select --YESNOPlease explain: (Mobility Issues) - 3rd Pet *Does your pet bite or bitten anyone in the past? - 3rd Pet *-- Please Select --YESNOPlease explain: (Reason For Bite) - 3rd Pet *Pet Information (4)Pet Name -4th Pet *Date of Birth -4th Pet *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet Type -4th Pet *-- Please Select --DogCatOtherBreed -4th Pet *Gender -4th Pet *-- Please Select --MaleFemaleWeight (LBS.) -4th Pet *Color -4th Pet *Spayed/Neutered -4th Pet *-- Please Select --YESNOPlease check if your pet(s) has had the following preventative health care services within the last year: -4th PetDistemperParvoInfluenza vaccineFlea and tick preventativePlease answer the following: -4th Pet Does your pet have any ongoing medical condition(s)? -4th Pet *-- Please Select --YESNOPlease explain: (Medical Conditions) -4th Pet *Is your pet currently receiving medication(s) -4th Pet *-- Please Select --YESNOPlease explain: (Medications) -4th Pet * Does your pet have Allergies/Skin allergies? -4th Pet *-- Please Select --YESNOPlease explain: (Allergies) -4th Pet *Does your pet have mobility issues? -4th Pet *-- Please Select --YESNOPlease explain: (Mobility Issues) -4th Pet *Does your pet bite or bitten anyone in the past? (4th pet) *-- Please Select --YESNOPlease explain: (Reason For Bite) - 4th pet *Vaccination and Hospital Authorization AgreementAnimal Hospital Name *Hyperactive Dogs & Accidents: There is always the possibility an accident could occur. Grooming equipment is sharp, even though we use extreme caution and care in all situations, possible accidents could occur including cuts, nicks, scratches, cracking of nails, etc. Every effort will be made to insure your dog(s) is groomed as safely as possible, but an excited dog can be dangerous to continue to work on and we reserve the right to end any and all services if deemed unsafe for the dog(s) or Coco Clips LLC. Staff. In the event of an accident during grooming Coco Clips LLC. will do its best to contact the owner; otherwise, we will take your dog(s) to our authorized veterinarian or to the nearest veterinarian that is available. It is agreed that all expenses for veterinary care will be covered by the dog’s owner upon signing this contract/agreement. *I have read, understand and agree to accept these terms. Current Vaccinations/Veterinarian Information: By signing this contract/agreement, owners/guardian verifies their dog(s) are current with their rabies vaccine and proof shall be provided to Coco Clips LLC. prior to any service such as grooming, bathing, nail clipping, and etc. Although we do not require your dog(s) to have all the vaccines other than required by law, we do recommend your dog(s) be fully vaccinated with what your veterinarian recommends to be fully protected for your area. Proof of Rabies Vaccination and Refusal of Service: An updated rabies vaccination is required by law and any form of documentation of vaccine history is required to obtain any service from Coco Clips LLC. Coco Clips LLC. reserves the right to refuse/stop services for your dog(s) at any time before or during any service. Veterinary care, Medical Problems & Senior Dogs: Grooming procedures can sometimes be stressful, especially for senior dogs or dogs with health problems, and can expose hidden medical problems or aggravate a current condition(s) during or after the groom. Senior dogs and dogs with health problems have a greater chance of injury; these dogs will be groomed for cleanliness and comfort, in a manner that will not add to their stress. In the best interest of your dog(s) this contract/agreement will allow Coco Clips LLC. to obtain immediate veterinary treatment for your dog should it be deemed necessary. Aggressive or Dangerous Dogs: Owners must inform COCO CLIPS LLC. staff their dog(s) bites, has bitten, or is aggressive to people, other dogs or specific grooming procedures. Muzzles may/will be used when necessary. Muzzling will not harm your dog(s), and protects both the dog(s) and the Coco Clips LLC. staff and you will be charge a special handling fee in addition to the regular grooming charge(s) and the charge(s) are not negotiable. Any and all bites must be reported to the local animal management division. COCO CLIPS LLC. Reserves the right to refuse service to any pet(s) that are deemed a danger to our staff. Client Communication: It is the Owner’s responsibility to inform Coco Clips LLC. of any change in contact information. Every attempt will be made to contact the Owner of the dog(s) in our care, however if no contact can be made Coco Clips LLC. will assume authority to make any decisions and actions that are in the best interest of the dog(s) in our care. Parasites: Coco Clips LLC. must be informed if you suspect your dog(s) has fleas, ticks or other parasites. If fleas or ticks are found during any service(s), your dog(s) will be treated with a product to kill the fleas and/or ticks and you will be charged in addition to your invoice. Ticks found will be removed for an additional charge in addition to your invoice. If ticks are found, we strongly suggest you have your dog(s) tested for Lyme disease. Should your dog(s) show evidence of internal parasites we reserve the right to end all service(s). Late Pick-Ups : If your dog(s) are not picked up 1 hour after the grooming appointment is complete, a charge of $35.00 will apply to your invoice. “Late Fee”. No-shows & Cancellations: We understand there may be emergency situations and will work with you. Please be respectful of our time as we are a by-appointment business. Note: Clients 15 minutes late risk losing their appointment without prior notice. Any cancellations must be made at least be 48 hours before the scheduled appointment date. Photos: Owner agrees upon signing this contract/agreement thatCoco Clips LLC. is allowed to take photos of their dog(s) before and after a groom to be used for advertising, posting on social media websites, third party affiliates, etc. Policy Changes: It is also understood and agreed the terms of this agreement/contract can change at any time, without notice, and will overwrite any and all prior signed contracts or documents.Vaccination and Hospital Agreement Acceptance *Yes, I have read and accept the terms in Vaccination and Hospital AgreementMatted Dog Release AgreementDogs with severely matted coats require extra attentionCoco Clips LLC. will not cause serious or undue stress to pets by de-mattingMats can be difficult to remove, and may require the pet to be shaved. (WE WILL ALWAYS CALL THE PET PARENTS PRIOR TO ANY SHAVE DOWN OF ANY BREEDS.) Removing a heavily matted coat can cause nicks, cuts, or abrasions. Heavy matting can also trap moisture and urine near the pet’s skin, allowing mold, fungus or bacteria to grow, and or revealing skin irritations that existed prior to the grooming process. After-effects of the mat removal can include itchiness, redness, self-inflicted irritations or abrasions, and failure of hair to regrow. In some cases, pets may also exhibit brief behavioral changes after shavedown. There will be extra charges for severely matted dogs. *I have read, understand and agree to accept these terms.Release of Liability of Coco Clips LLCI hereby release COCO CLIPS LLC. from any liability associated with any and all injuries or medical problems that may be uncovered and or occur during the stripping and de-matting process. Should my pet need veterinarian care after or during the process of de-matting, I agree to pay any and all veterinarian fees *Yes, I agree to the release of liability of Coco Clips LLC. as stated above. I am responsible and will accept and agree to pay all costs incurred as result of the de-matting process regardless of whether the expense was a result of effects that happed before, during and/or after the de-matting process.Acknowledgement & Acceptance of the Matted Dog Release Agreement *I have read, understand and agree to accept to the terms in the Matted Dog Release AgreementHow did you find us?How did you become aware of our services?-- Please Select --GoogleYelpFrends and FamilyBingSign/FlyerEventPayment PolicyPayment Policy All client services must be paid in full prior to dogs leaving the salon Coco Clips LLC Accepts the follow payment resources: VisaMastercard Discover CardCashDebit Cards If any payment is declined, or returned a $50.00 fee Team member gratuity, may be added to total service. If gratuity is paid in cash, it will be placed in the team member’s gratuity envelope. Team members are encouraged to pick up their envelopes everyday after shift ends. All payments must be made when services are rendered or deposit made before services are rendered. Accepted methods of payment include Cash, Discover, Visa and Mastercard. An estimate can and will be prepared upon my request. *Yes, I understandPayment Policy Agreement Acceptance *Yes, I have read and accept the terms in Payment Policy AgreementFull Name of Authorized Signing Person *FirstLastAcknowledgement and Acceptance *Yes, I have read and understand this form and all of its agreements in its entirety and agree to abide by all of the terms and conditions listed above as it applies to all the pet(s) listed on this form.Signature Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SignatureClear SignatureSubmit