Intake Form - Whiskers 2 Toes LLC

Name*

First Last

Email Address*

Phone Number*

Address*

Street Address City 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

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