Canine Intake Form.Your contact information and your dog’s health history. Your Name * First Name Last Name Phone Number * (###) ### #### Email * Preferred Method of Contact * Email Phone Text Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Dog's Name * Sex * Spayed Female Unaltered Female Neutered Male Unaltered Male Tell me about your pet (breed, age, activities, medical conditions, trauma, etc). * Veterinarian First Name Last Name Veterinarian's Phone Number (###) ### #### Physical Observations Have you noticed if your dog prefers to sleep/sit on one side over the other? Have you noticed any change in their movement, getting up, laying down, getting into and out of the car, etc? Have you noticed any changes in their gait (walk, trot, run)? Is there anywhere your dog does not like to be touched? Permission to do bodywork * By checking the box below, I give Katherine Berry permission to perform bodywork on this dog. I understand massage or other modalities are never a replacement for proper veterinary care. I understand that Katherine Berry, as a Small Animal Massage practitioner will not diagnose conditions, attempt any adjustments/musculoskeletal manipulations or prescribe medications, nutraceuticals, or supplements for my animal. If a veterinarian is currently seeing this animal, I have cleared this work with the attending veterinarian to ensure bodywork is at this time appropriate for the dog or cat. I affirm that I have given all relevant information and will update you when new information is acquired. * Yes No Thank you for the taking the time to tell me about your dog! I will be in touch with you soon. Meanwhile, this might be a good time to look at the What to Expect from a Dog Massage page.
