Welcome to TheraPaws!
917 West Foothill Boulevard, Upland California 91759 (909) 202-7582
TheraPaws New Client Form
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Owner(s) Name(s)
First Name
Last Name
Pet's Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
Veterinarian Name and Number
Type of Pet
Please Select
Dog
Cat
Equine
Camel
Other
Age
Spayed/Neutered
Please Select
Yes
No
Don't Know
Where did you obtain your animal companion? At what age?
Other Companions at Home? Type? How Many? Do They Get Along?
Does your pet live...
Please Select
indoors
outdoors
both indoors and outdoors
Current Injuries and Symptoms (describe)
Current Medications
Types of Allergies
Skin Conditions
Please Select
yes
no
sometimes
What are you looking to acheive
Is your pet sensitive to touch/pressure? Where?
Please list any history of aggression or behavioral problems
What do you feed your pet? (include daily amounts for meals and treats)
Last professional teeth cleaning
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
List any surgeries other than spay/neuter
Check any of the following conditions that apply to your pet
seizures
hip dysplasia
elbow dysplasia
osteoarthritis
Intervertebral Disc Disease
Total/Partial Deafness
Blindness
Breathing Difficulty
Heart Murmur
Diabetes
Kidney Disease
Liver Disease
Is your pet up-to-date on his/her rabies vaccination
Please Select
yes
no
unsure
Please list anything that your pet likes or dislikes in terms of touch, food, toys, etcetera.
Is there anything else we should know about your pet?
I hereby agree that the information on this form is correct and that I consent to therapy for my pet at Therapaws.
Please Select
agree
disagree
Signature
Submit
Should be Empty: