Order Number

First Name *

Last Name *

Mobile Number *

Email Address *

Address *

City *

Zip *

State *

- Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Dog name *

Gender *

Male Female

Dog breed *

Spayed or Neutered?

Yes No

Veterinarian and Clinic Name *

Does your pet have a heart disease? *

Yes No

Is your pet pregnant or nursing? *

Yes No

Is your pet under sedation? *

Yes No

Are they any health or behavioral issues? (example: respiratory disease, seizures, arthritis, injuries, open wounds, etc. *

Yes No

If so, please explain

Grooming Agreement Terms and Conditions (Please select Yes if you accept) *

Yes No QC Canine Design requires proof that each pet’s Rabies vaccine is current. Also, we highly recommend that your dog be vaccinated against all infectious conditions, as followed: Parvovirus, Bordetella, Distemper and Parainfluenza. It is still possible for vaccinated pets to become ill with a infectious condition despite being vaccinated. This is not due to any circumstance or condition in the Grooming Salon and you agree that you will not hold QC Canine Design liable in the event that your dog becomes ill with an infectious condition during or after the dogs stay. QC Canine is not responsible of allergic reactions resulting from the manufacturer-recommended usage of any products. Although a pet may experience an allergic reaction to grooming products at anytime. Tick and Flea products are associated with a larger risk of a reaction. Please ask your vet before having your dog treated if you have any concerns or questions. Here at QC Canine Design your pet’s health is our main concern. For that reason your dog may be tethered during the grooming service. If we feel the well-being and safety of your dog and /or a salon associate is in jeopardy a muzzle may be used or services refused/discontinued. QC Canine Design is not responsible for pre-existing medical conditions or the aggravation of those conditions such as arthritis, obesity, heart disease, or any other medical problem that may be affected by the grooming process. An Express Groom is available for an additional charge if you feel that your dog would benefit from being in the salon for a shorter period of time. In case of an emergency, the owner designates QC Canine as agent and understands that QC Canine Design will do whatever is appropriate for the well-being of your pet while in our care. If your dog becomes sick or injured and requires professional attention we will attempt to contact you. However, if we are unable to contact you, QC Canine Design at its sole discretion may engage the services of a veterinarian and the expense shall be paid by you. Photos. We may take a photo of your pet while your pet is receiving our services or in our care (photo). You hereby grant QC Canine Design and its subsidiaries the perpetual, irrevocable , royalty-free right and license to publish, distribute, adapt, modify, or otherwise use the photo, or any portion thereof, in any manner for any commercial or non-commercial purpose without your notice, review or approval. Any Pet not picked up from the salon within 24 hours of completion of a service may be turned over to local human society or adoption agency.

Matted Pet/Spot Shave Authorization (if applicable) *

Yes No

Shave Authorization for Body Shave Down (if applicable

Yes No

Date *

Owner or Agent Digital Signature *