Client Intake & Consent Form

If you would like to set up a session with me, please fill out the intake & consent form below. Within 24 hours, you will receive an email from Eri Suzaki, the therapist to schedule a date.

Name *

First

Last

Email *

Home street address (Required for house call)

City, State, Zip

Your Phone *

xxx-xxx-xxxx

I would like to book for: *

Your Dog's Name *

Your Dog's Birthday or Age *

e.g. 'xx years old' or 'MM/DD/YYYY'

Your Dog's Breed *

Spayed/neutered? *

Primary veterinarian *

Recent injury or any history of injury? *

Please describe the recent injury or any history of injury (if you answered "Yes" to the above question.)

Recent surgery or any history of surgery? *

Please describe the recent surgery or any history of surgery (if you answered "Yes" to the above question.)

Please list any medication that you give to your dog

Please list any supplements of any type that you give to your dog

Where did you hear about Canine Therapeutics? *

Is it OK to share your dog's photos on social media and print? *

I, (dog owner) have disclosed all the information about my dog's physical condition to Canine Therapeutics and understand that massage is not a substitute for veterinary medicine. I (dog owner) agree that in case of cancellation made in less than 24 hours, 50% of the session fee will be billed to me. Please type your name as your signature below: *

Date of your signature: *

MM/DD/YYYY

Message

Client Intake & Consent Form

Canine Therapeutics

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