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672-200-DOGS (3647)

info@caninesparkleandshine.com

CANINE SPARKLE & SHINE

INTAKE FORM

First and last name (owner)*

First and last name owner #2 (if applicable)

Contact number*

Contact number #2 (if applicable)

Email*

Email #2 (if applicable)

Street Address*

City*

Province*

Postal Code*

Dog's Name *

Dogs Gender*

Female

Male

Breed*

Weight*

Dog's birthday*

Year

Month

Day

Has your dog seen the Veterinarian within the last year?*

Yes

Any known medical conditions?*

Please include any medications

Any known allergies?*

Please check all that apply*

Previous Sedation Free teeth cleaning

Previous Anesthesia deep cleaning at Veterinarian

TLC - slightly nervous

Has bitten someone

Needs anxiety medication for grooming/veterinarian visits

Spayed or Neutered

Takes daily medication

Please elaborate in box below and let us know if there is anything else that isnt included that applys to your dog.

Please tell us a little bit about your dog! We want to make their sedation free teeth cleaning experience as comfortable as possible.

Please select box(es) below of how you wish to be notified of appointments:

Text

Call

How did you hear about us*

I consent that all the above statements are true.

I consent that a 24HR cancellation notice on all appointments is required or a $50 sitting fee will be applied.

Signature

Signature field is empty.

Date and time

Year

Month

Day

Time

:HoursMinutes

LOCATION

1702 - 138 Esplanade East

North Vancouver, BC

Canada V7L 4X9

Opening Hours:

Sunday: 9am - 5pm

CONTACT

Thanks for submitting!

We do not diagnose, consult or give any oral health recommendations.

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