New CANINE Client Intake Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Accept text at this phone number?

YESNO

Email

example@example.com

Dog's name

Age

Breed

Color

Spayed or Neutered? (Yes or No)

Level of Daily Activity (Please mark one)

HighMediumLow

Types of Activities

Veterinarian

Vet's Phone

Medications/Supplements Being Taken

Please indicate any of the following conditions that your dog currently has:

allergies

Detail's for the above checked items

Does your dog have any difficulty lying on their front, back, or side?

YesNo

If yes, please explain

As the owner, do you feel your dog is currently under stress?

YesNo

If yes, please explain

Is your dog nervous or aggressive around strangers or strange places?

YesNo

If yes, please explain

Is there any particular area where you think your dog is experiencing tension, stiffness, pain, or other discomfort?

YesNo

If yes, please explain

Is your dog current with their vaccinations?

YesNo

Is there anything else about your dog's health history that would be useful for the massage therapist to know?

Release of Liability:

I am allowing my dog to receive massage therapy. I understand that massage is not a substitute for medical treatment or medications, and that it is recommended that work with my Veterinarian for any medical conditions that my animal may have.

DOG OWNER/GUARDIAN HAS BEEN NOTIFIED THAT MASSAGE THERAPY/COLD LASER THERAPY/CORE MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY/ACUPRESSURE ARE NOT SUBSTITUTES FOR VETERINARY CARE/MEDICINE. THEY DO NOT DIAGNOSE; IF YOUR DOG APPEARS TO BE ILL, OR INJURED,

PLEASE CONTACT YOUR VETERINARIAN IMMEDIATELY.

DOG OWNER/GUARDIAN HAS BEEN NOTIFIED THAT PAYMENT MUST BE MADE UPON ARRIVAL OF THE MASSAGE THERAPIST. IF PAYMENT is NOT MADE AT THIS TIME, THERE WILL BE NO SERVICE PROVIDED.

THERE ARE ABSOLUTELY NO EXCEPTIONS TO THIS POLICY.

DOG OWNER/GUARDIAN HAS BEEN NOTIFIED THAT CEILAJ. REILY D.B.A. UNIVERSAL CONNECTIONS, LLC RESERVES THE RIGHT TO MAINTAIN A 24 HOUR CANCELLATION POLICY. APPOINTMENTS MUST BE CANCELLED WITHIN 24 HOURS OF THE SCHEDULED MEETING; OTHERWISE, CLIENTS WILL BE CHARGED $35 FEE FOR SERVICES. EXCEPTIONS CAN BE MADE TO THIS POLICY.

DOG OWNER/GUARDIAN WILLFULLY AGREES TO SUBMIT HIS/HER CONSENT TO ALLOW CEILA J. REILY D.B.A. UNIVERSAL CONNECTIONS, THE PERMISSION TO PERFORM MASSAGE THERAPY/COLD LASER THERAPY/CORE MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY /ACUPRESSURE INTERVENTION ON HIS/HER DOG TODAY AND ON ALL FUTURE DATES.

DOG OWNER/GUARDIAN AGREES TO RELEASE CEILA J. REILY D.B.A. UNIVERSAL CONNECTIONS, FROM ANY LOSS, DAMAGE, LIABILITY OR INJURY ARISING OUT OF, OR RESULTING FROM, PARTICIPATION IN CANINE MASSAGE THERAPY/COLD LASER THERAPY/CORE MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY/ACUPRESSURE, INCLUDING ANY NEGLIGENT ACTS.

DOG OWNER/GUARDIAN AGREES TO INDEMNIFY, HOLD HARMLESS AND DEFEND CEILA J. REILY D.B.A. UNIVERSAL CONNECTIONS, FROM ANY LOSS, DAMAGE, LIABILITY, OR INJURY, HOWEVER, CAUSED, RESULTING DIRECTLY OR INDIRECTLY FROM HIS/HER PARTICIPATION, OR FROM ACTS OR OMISSIONS. DOG OWNER/GUARDIAN ACKNOWLEDGES THAT ACTIVITIES WITH AND AROUND DOG INVOLVE INHERENT RISKS OF PHYSICAL INJURY TO PARTICIPANTS, DOG AND TO OTHERS WHICH DOG OWNER/GUARDIAN UNDERSTANDS AND EXPRESSLY ASSUMES.

The undersigned hereby execute and deliver this agreement. I hereby state UNDER THE PAINS AND PENALTIES OF PERJURY that I have read this INFORMED CONSENT FORM/RELEASE OF LIABILITY in complete detail, understand the consequences thereof, and execute this instrument as a sealed instrument on this date

Today's Date

Date

Name

First NameLast Name

Signature

Optional:

I hereby grant CEILA J. REILY D.B.A. UNIVERSAL CONNECTIONS, the right to take photographs and videos of me and my property (i.e. horse) in connection with the above identified subject. I authorize CEILA J. REILY D.B.A. UNIVERSAL CONNECTIONS, its assigns and transfers to copyright, use and publish the same in print and/or electronically. I agree that CEILAJ. REILY D.B.A. UNIVERSAL CONNECTIONS, may use such photographs and videos of me and or my property (i.e. horse) with or without my name and for any lawful purposes, including but not limited to publicity, illustration, advertising, and web content.

Signature

Today's Date

Date

Canine Massage Intake Form