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Contact Information
Please complete this initial Contact Information form. This form is not a contract for services. This form is the first initial intake form which provides us with history, personal needs, and general information that we need to know before we provide massage services.
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Email
*
Your email
Name
*
Your answer
How did you hear about us?
*
Your answer
Dates requested for services:
*
Your answer
Preferred time frame for massage services:
(Example: Tuesdays, between 1:00 p.m. and 2:00 p.m.)
*
Your answer
Owners Name
*
Your answer
Email
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
For Canine Massage, please provide us the
names
,
genders
,
ages
, and
breeds
for each of the pets that live in your home. (please list all animals, reptiles, fish, birds, etc.).
If Equine Massage, please provide us with Horse's name, breed, color, and age.
*
Your answer
Are there any medical needs that we need to be aware of?
(this includes medications, allergies, pain issues, urinary issues, recent medical issues, etc.) If yes, please explain here.
*
Your answer
History of fear, anxiety or nervousness in your animal?
If yes, please explain here.
*
Your answer
Is there a history of biting or aggression?
If yes, please explain here.
*
Your answer
I would like to add-on one or more of the following services:
*
Animal Reiki - can be provided in person or virtually by a member of our team who is a certified Animal Reiki Practitioner (Animal Reiki can be provided remotely)
Canine Massage - by a member of our team who is a certified Equissage Practitioner
Equine Massage - by a member of our team who is a certified Equissage Practitioner
I would like to talk to someone about one of the above services before adding it on
No other services are needed at this time
Required
Veterinarian and contact information:
*
Your answer
Are vaccinations current?
*
Your answer
Local emergency name and phone number in case we are unable to reach you:
*
Your answer
A copy of your responses will be emailed to the address you provided.
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