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Bath/Grooming Release Form

Locust Valley Veterinary Clinic

280 Forest Ave

Locust Valley, NY 11560-2150

United States

(516) 676-6161

Client Full Name:

*

Client Address:

*

Contact Phone #:

*

Patient Name:

*

Patient Species:

*

Patient Breed:

*

Patient Age:

*

Patient Sex:

*

Patient Weight:

*

Emergency Contact Person:

*

Emergency Phone #

*

Do you need a refill on preventatives?

*

Do you need a refill on preventatives?

A

Yes

B

No

Signature of Owner or Authorized Agent:

*

Signature

Date:

*