New Client Intake Form "*" indicates required fields Name* First Last Email Address* Phone Number*Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred method of contact?* Email Phone Both Dog's Name*Dog's Breed*Sex* Male Female Status* Spay Neuter Date of Birth*Color / Markings*Is your dog a service / therapy dog?* Yes No Current Veterinarian Name*Veterinarian Phone Number*Is your dog up to date on vaccinations?* Yes No Is your dog on any medications* Yes No Which medications?*Has your dog had any surgery within the past year?* Yes No What and when?*Has your dog had an injury that is still affecting him/her?* Yes No Please explain.*Is your dog experiencing any problems with daily activities?* Yes No What are they?*Is your dog involved in any competition or sport?* Yes No What does your dog participate in?*Has your dog had a massage before?* Yes No 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.By submitting this form I confirm that I have read the above statement.* I confirm CAPTCHA
