Date of Appointment Date Format: dd-mm-yy
Phone*
Email*
My Dog's Pics
Dog Name*
Age*
—Please choose an option— 1 Yr 1.5 Yrs 2 Yrs 2.5 Yrs 3 Yrs 3.5 Yrs 4 Yrs 4.5 Yrs 5 Yrs 5.5 Yrs 6 Yrs 6.5 Yrs 7 Yrs 7.5 Yrs 8 Yrs 8.5 Yrs 9 Yrs 9.5 Yrs 10 Yrs 10.5 Yrs 11 Yrs 11.5 Yrs 12 Yrs 12.5 Yrs 13 Yrs 13.5 Yrs 14 Yrs 14.5 Yrs 15 Yrs 15.5 Yrs 16 Yrs 16.5 Yrs 17 Yrs 17.5 Yrs 18 Yrs 18.5 Yrs 19 Yrs 19.5 Yrs 20+ Yrs
Breed*
Gender
Male Female
Spayed/Neutered
Yes No
History
Last vet visit*
Preferred vet Office*
Has your dog ever bitten anyone? Please provide details*
How did you hear about K9 Gentle Dental?
Anything else we should know about your dog?
K9 Gentle Dental Waiver
All animals (in particular older ones) can have unknown underlying health issues and there are always risks involved while working with animals as they can be unpredictable.
K9 Gentle Dental will take every precaution when handling your pet to do our very best to keep them safe while they are in our care. Your pets’ well being is extremely important to us.
I acknowledge that there are inherent risks to my pet in the performance of these services, including, but not limited to cuts, abrasions, infections, allergic reactions, muscle sprains or strains, or adverse reactions due to stress or undiagnosed health/dental issues.
I understand and acknowledge that the representatives of K9 Gentle Dental are not veterinarians and will not perform any veterinary medicine. I understand that sedation free cleanings are a hygienic service and not meant to replace visits to a veterinarian or any veterinary dental service of any kind.
I understand that any information provided by the K9 Gentle Dental team members should be provided to my vet for follow up inspection. Without advising my veterinarian about performing this dental cleaning, I understand that it may make it more difficult for them to recognize areas of concern in my dogs’ mouth. I have been informed that my dog could potentially have dental issues that should be seen by a veterinarian. I have been informed that a sedation free cleaning may not be sufficient for my dog to maintain their oral health. I understand that there are limitations to sedation free cleanings, including the lack of any diagnosis or treatment. I have chosen to continue with a sedation free cleaning, which may leave underlying dental issues unresolved.
I agree that the services provided by K9 Gentle Dental are provided solely at my risk, and hereby waive and release K9 Gentle Dental, its directors, officers, employees, shareholders, volunteers, representatives, agents and the host business and its employees and representatives (the “Released Parties”) and indemnify and hold the Released Parties harmless from and against any and all liabilities, claims, demands, causes of action, judgments, costs or expenses (including legal expenses) which K9 Gentle Dental or the Released Parties may suffer, sustain or incur as a result of any act or omission of any nature or kind whatsoever arising out of, or in the course of the performance of the Services.
LATE DROP OFF & PICK UP
Due to the nature of our appointments, late drop off cannot be accommodated. It is understood that if I am more than 10 minutes late for my appointment I will need to reschedule and my deposit will not be refundable. I am also aware that if I am more than 10 minutes late to pick up my dog a $50+gst late fee will be added to my bill.
Price: Total Cost of anesthesia-free teeth cleaning: $249+gst = $261.45
Who will be bringing your pup in to see us
Yourself Somebody else They will be in daycare
By checking this box I agree to all stated in this document and understand that in absence of a signature this will act as my approval to proceed with services.