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Canine Client Intake Form

Your Name (required)

Your email address (required)

Your Telephone (required)

Your Mailing Address (required)

Preferred method of Contact?
 Email Phone Both
Dog's Name

Breed

Sex  Male Female
Sterilization  Spay Nueter
Date of Birth
Color/Markings
Is your dog a service/therapy dog?
Current Veterinarian Name and Contact Info

Is your dog up to date on vaccinations?

Is your dog on any medications? *If yes…What are they?

Has your dog had any surgery within the past year?*If yes…What and when?

Has your dog had an injury that is still affecting him/her? *If yes…Please explain.

Is your dog experiencing any problems with daily activities? If yes…What are they?

Is your dog involved in any competition or sport? Ie Dog Shows, Agility, Fly Ball etc.

Has your dog had a massage before? If yes…When and where?

Why is your dog having a massage performed now?

Did I miss anything? Please feel free to add additional comments or anything I need to know!

I understand that massage and other modalities are never a replacement for veterinary care and/or treatment. I understand that the massage therapist is certified to provide massage for animals and will not diagnose or prescribe treatment, attempt any adjustments/musculoskeletal manipulations (though the dog will sometimes adjust themselves during a massage) nor prescribe any supplements or medication for my dog. If my dog is currently under veterinary care, I have cleared this work with the attending veterinarian to ensure massage is at this time an appropriate and safe decision.

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