Client Intake & Consent Form

Your Name (required)

Your Email (required)

Home address (Required for house call)

Your Phone (required)

I would like to book for: (required)
---30 minute-massage (suitable for small dogs or quick maintenance)60 minute-massage120 minute-massage (can be shared by two dogs)Massage + cold laser (30 minutes total)Massage + cold laser (60 minutes total)Cold laser only (approx. 15 minutes)Core training + Massage (60 minutes total)Couple's massage for you & your dog (60 minutes)House call for 60 or 120 minute-massageHouse call for Massage + cold laser (60 minutes)

Your Dog's Name (required)

Birthday or Age (required)

Breed (required)

Spayed/neutered? (required)
---Yes, Spayed/NeuteredNo

Primary veterinarian (required)

Recent injury or any history of injury? (required)
---YesNo

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? (required)
---YesNo

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? (required)

Is it OK to share your dog's photos on social media and print? (required)
---Yes, you may use my dog's photo on social media and print.No, you may not use my dog's photo 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: