YOUR INFORMATION

Name E-mail

Address

City, State, Zip

Neighborhood

Home Phone

Cell Phone

Vet Name

Vet Phone

TODAY'S Date

Which Location Do You Plan to Visit?

How Did You Hear About Us?

Each month, we offer great discounts to our clients by email. Would you like to be included in our monthy email?

A couple of IMPORTANT items you need to know about us:
(1) At That Dirty Dog, we are a NO FLEA ZONE! Please, if you know your dog has fleas, let us know. We sell CAPSTAR- a pill you can safely give your pet that will kill fleas in one hour so you can come back later that day for the bath.
(2) With all due respect, we are not liscensed as a holding facility. If you are leaving your pet for us to attend to, have you made arrangments to be back in the time frame quoted by a staff member?
PET INFORMATION

First Pet's Name Age Breed Birthday

Date of last rabies shot:

Please not allergies, physical conditions, or behavior issues below:

Second Pet's Name Age Breed Birthday

Date of last rabies shot:

Please not allergies, physical conditions, or behavior issues below:

Third Pet's Name Age Breed Birthday

Date of last rabies shot:

Please not allergies, physical conditions, or behavior issues below:

WAIVER OF LIABILITY

I hereby waive and release That Dirty Dog Inc and its owners and employees from any and all liability of any nature
for any injury or damage which my pet may suffer, including specifically, but not without limitation to, any injury or
damage resulting from the action of any other on the premises, any washing or grooming activity that I or the
employees of That Dirty Dog participate in along with my pet, and I expressly assume the risk of such damage or injury.
I hereby waive and release That Dirty Dog Inc and its owners and employees from any and all liability of any nature
for any injury or damage which my pet may suffer, including specifically, but not without limitation to, any injury or
damage resulting from the action of any other on the premises, any washing or grooming activity that I or the
employees of That Dirty Dog participate in along with my pet, and I expressly assume the risk of such damage or injury.

YES NO

I understand that if I leave my pet at That Dirty Dog and exit the premises, my pet may be put in a cage until my return.
If more than 45 minutes elapses, a charge of $25 dollars dollar for every 15 minutes beyond 45 minutes will incur.

YES NO

For the safety of patrons and That Dirty Dog staff, my pet may be gently and humanely muzzled if necessary.

YES NO

If I am washing my own pet, I will not introduce my pet to to other pets if the owner is not present. I understand
staff may be working on a pet, and I will keep mine from engaging in any contact.

YES NO

That Dirty Dog reserves the right to refuse service to any pet that is determined by the management or pet owner as
being aggressive or displays dangerous behavior.

YES NO

I hereby agree to indemnify and hold harmless That Dirty Dog and its employees from any and all claims. This
waiver of liability will stay in effect unless I explicitly revoke it in writing.

YES NO

I certify that I am 18 years or older

YES NO

SIGNATURE

Typing your name in the box below will serve as your binding signature.

Signature //