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FORM AGREEMENT – TEST EMAIL

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Thank you for allowing BRIGHT N’ SHINE PET DENTAL® to be part of your pet’s life and for allowing us to be a partner in improving his/her long-term dental health. In order to perform the nonanesthetic dental procedure on your pet, we will need this form to be complete and signed. By signing this agreement, the pet owner agrees not to hold BRIGHT N’ SHINE PET DENTAL®, their technicians, associates, and the establishment responsible for any and all claims, demands, or causes of action, liability, loss, damages, or expenses, including attorney’s fees and cost, arising out of or in the course of any pet teeth cleaning activity. Bright N’ Shine, LLC technicians may recommend the use of CBD oil, if needed, as a homeopathic relaxant to calm your pet. During the dental cleaning procedure, we use Therasol to soften the tartar, and we may recommend the use of non-prescriptive Chlorhexidine. Your pet may be lethargic until the relaxant wears off. This will vary from pet to pet This LIABILITY WAIVER AND HOLD HARMLESS AGREEMENT shall include any claim, demand, or cause of action against all companies or any of its employees, officers, or shareholders for negligence and/or strict liability.

Owner Name*

Primary Phone Number*

Email*

How did you hear about us?*

ZipCode*

I agree to receive text messages about my schedule.

Yes

I consent to receiving text messages about promotions and products.

Yes

Pet name*

Pet Type*

Weight*

Breed*

Pet Date of Birth

MM slash DD slash YYYY

Pet Age*

Spayed/Neutered*

Yes

No

Pregnant*

Yes

No

Does your pet have any health issues or concerns that the technician should know about (heart, kidney, convulsive disorders, recent surgeries, allergies etc.)

Is your pet on any medication? If so, which one(s)?

Is your pet current with their Rabies vaccinations?*

Yes

No

UNKNOWN

Do you approve for us to use CBD Oil*

Yes

No

Could you indicate a friend?

Friend phone

Could you indicate your grooming or pet shop?

Grooming phone

Could you indicate your dentistry?

Dentistry phone

Owner Signature*

Technician Signature*

Technician Area*

SENIOR PET / SPECIAL CONDITIONS WAIVER

We care about your pet’s safety and well-being; we want to assure you that every effort will be made to make your senior pet’s service as pleasant as possible. Pre-existing medical conditions including loose teeth, Acts of God, or any other event beyond our control can cause emergency situations. We cannot be held liable for their outcome. I release BRIGHT N’ SHINE PET DENTAL® and its employees from all responsibility if my pet(s) is injured in any way during the procedure, or in the case of sudden death. I understand that all precautions will be taken for the safety and welfare of my pet(s). With my signature below I certify that I have read and understand the agreement and waiver. I agree to abide by and accept all terms and conditions as set out. Please ask for clarification if necessary.

THIS FORM MUST BE EMAILED OR HAND-DELIVERED TO BRIGHT N’ SHINE PET DENTAL® WITH AN ORIGINAL SIGNATURE PRIOR TO SERIVCE.

Owner Signature*

Technician Signature*

Name

This field is for validation purposes and should be left unchanged.

Franchise

Technician

Sales Team

Referal Program

Marketing

Non-Anesthetic Cosmetic Dental Cleanings
Safe – Affordable – Convenient

First Name

Last Name

Phone Number

Zip Code

Email

Pet's Name

Age

Breed

Approx Weight

Suggested Date

Suggesst Time