Information and Consent Form

Name*

First NameLast Name

Address*

City*

State *

Postcode*

Work/Mobile Phone*

Format: (000) 000-0000.

Email*

example@example.com

Dogs Name*

MaleFemale

YesNo

Breed*

Birth date or Age*

Weight*

Medical Conditions (including physical)*

Medications / Heartworm or Flea Prevention*

What do you feed your dog? What does your meal time routine look like?*

Main behaviour struggle you want help with?*

e.g. pulling on the lead, barking etc.

Any other struggles?*

e.g. over excited, jumping etc.

Any other pets in the homes? Please list*

Is your dog nervous of people?*

Tell us something good that your dog does and what you enjoy about them*

What is your dream or long term goal for you and your dog? Please give as much detail as possible*

e.g. calm walks, travel well in a car

Would you like to add anything else about your goals, experiences or circumstances e.g. you have a time limit, neighbours’ complaints, baby on the way etc.*

Yes, that is okayNo, thank you

I understand I have paid a fee for this service. I am the owner or the representative for the owner of the animal described above, and I have the authority to execute this consent.

I hereby consent and authorise Emma Hamilton and/or Emily Sirc of Paws Mindfully to perform the following procedures or services:

I understand that the information I receive does not replace veterinary behaviourist and /or care. This service and /or products are not intended to diagnose, treat, prevent, or cure diseases. I understand that no guarantee or assurance can be made as to the results that may be obtained from the training sessions. It is understood that I assume all risks involved with any training strategies including aromatherapy options or any other natural suggestions for the above listed animal.

Yes, I agree

(Owner/Authorised Representative Signature) Signature*

Date*

Date