Intake Form
For canine massage and acupressure.
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Email *
Guardian/Owner's name: *
Address: *
Phone number: *
Dog's name, breed, age: *
Dog's gender: *
Spayed/neutered? *
Vet information (clinic name, vet name, phone number): *
Do I have permission to talk to your vet if it is applicable? *
Dog's activities (and level of activity): *
Injuries/diseases/conditions: *
Medications: Please list name and dosage *
Food/supplements: Please list name, amount and frequency given as well as food sensitivities/allergies if applicable. *
What is the reason you've chosen massage/acupressure for your dog? What goals do you have? *
If the reason involves a medical condition, injury or lameness, has your pet seen a veterinarian for it? *
Has your dog had bodywork before (massage, chiropractic, acupuncture, etc.)? If so, which one and how did your dog respond to it? *
Does your dog have any behaviors you want me to be aware of (fears, shy with new people, specific areas that he/she is reluctant to have touched)? *
Referred by:
Bodywork is not a replacement for veterinary care. Canine Massage Therapists cannot diagnose and/or treat illness, injury or lameness. Massage Therapy as provided by Helga Karisch includes a variety of complementary modalities, all within a licensed SAMP’s scope of practice, which support the health and well-being of the client physically and emotionally. I understand that I have to give at least 24 hours notice if I have to reschedule or cancel an appointment. I do not expect a reminder call prior to my appointment unless I request one. *
Signature: *
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