NEW CLIENT INTAKE FORM (For Animal Massage and/or Reiki)

First and foremost, the safety and well-being of your dog(s) is of the highest importance to TranquilPET. Ensuring that your pet remains safe and well cared for is our first responsibility and as such we take it very seriously.

Therefore, TranquilPET requires written vet approval for all senior dogs and/or dogs under veterinary care with a “current” medical condition before massaging and/or swimming your dog(s). Without this written veterinarian approval, TranquilPET will not touch your dog(s). [VETERINARIAN APPROVAL FORM Link] (Vet approval not required for Reiki as Reiki is offered "hands-free.")

* Please note: Each dog is different and each session will be tailored to meet the individual needs of your pet.

How did you find TranquilPET? [VET/FRIEND/CLIENT/GOOGLE SEARCH]*

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Phone Type*

Cell PhoneWork PhoneHome Phone

Email*

example@example.com

Pet's Name (1)*

Pet's Age*

Pet's Breed*

Pet's Weight*

Pet's Gender*

MaleFemale

Is your pet neutered/spayed*

YesNo

Pet's Name (2)

Pet's Age

Pet's Breed

Pet's Weight

Pet's Gender

MaleFemale

Is your pet neutered/spayed

YesNo

(Please put “N/A” if not applicable)

VETERINARIAN(S):

Regular Vet:*

Regular Vet's Phone Number:*

Orthopedic Vet:

Orthopedic Vet's Phone Number:

Does TranquilPET have permission to contact any of the health providers listed above, should I have further questions regarding your pet’s participation in any of our holistic programs?*

YesNo

ANIMAL MASSAGE:

What are your goals for animal massage?:*

For Jean to massage my dogTo learn how to give a relaxation massage to my dogI am not interested in animal massage at this time

What type of animal massage class:

Group Session (Your dog must be people and dog friendly)One-on-One

How to prepare your dog for individual or group animal massage class:

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NO FOOD 4-6 hours before your dog’s massage.

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POTTY YOUR DOG. If s/he is having problems with bowel movements, please let me know.

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FOR THE ADDITIONAL COMFORT OF YOUR DOG: Bring your dog's bed, pillow, or favorite throw.

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YOUR DOG WILL SOCIALIZE FOR AT LEAST 15 MINUTES PRIOR TO CLASS BEGINNING.

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ALL MASSAGE LESSON WORK IS DONE ON FLOOR. So bring a mat, pillow, or whatever you may need.

REIKI MEDITATION:

What type of Reiki meditation:*

Group Session (Your dog must be people and dog friendly)One-on-OneI am not interested in Reiki at this time

Thank you for your cooperation and understanding.

By signing below, you acknowledge receipt of and adherence to the above.

Signature*

Date*

Date

MY PET'S PHYSICAL AND MEDICAL CONDITIONS:

Current injuries?*

YesNo

Date of injury, if applicable

Please describe injury, if applicable

Current surgery?*

YesNo

Date of surgery, if applicable

Please describe surgery, if applicable

Does your dog(s) have any (Must have your VETERINARIAN APPROVAL FORM Link - Not required for Reiki as Reiki can be offered "hands-free"):

Heart issues?*

YesNo

Breathing issues?*

YesNo

Skin Conditions?*

YesNo

If yes to the above, please describe:

Please list any medications and/or supplements you currently give your dog.

Flea and tick control medication:*

OralTopical

Medication Name: *

If topical, date of last application*Type a question

VACCINATION HISTORY: *Please attach copy of vaccination records

Your pet must be current on the following vaccinations:

My dog has had the:*

Rabies VaccineTiters Test

Date of last Rabies Vaccination /Titers Test (1 to 3 years):*

Other Vaccinations: (Please attach here, or bring a physical copy to your first swim)

ADDITIONAL INFORMATION:

Is your pet sensitive to touch or have “no touch zones”?*

YesNo

Where?

Has your dog ever bitten anyone or another dog?*

YesNo

If yes, please describe situation:

Does your dog have issues/fears/dislikes with:

Other dogs*

YesNo

Strangers/Men/Women/Children*

YesNo

If yes, please explain:

Is there anything else that I should know about your pet?*

YesNo

If yes, what?

Initial

I acknowledge that my pet is not under a vet’s care for a current medical condition, and, therefore, no Vet Approval Form.

Initial is required.

OR

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My pet is under a vet’s care for a current medical condition and I have discussed with my vet and have received his/her approal. My Vet Approval has been received and their written form is attached.

Initial is required.

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I UNDERSTAND THAT ANY HOLISTIC APPROACH (DOG SWIMMING, ANIMAL MASSAGE, REIKI, ETC.) DO NOT TAKE THE PLACE OF PROPER VETERINARY CARE FROM A DOCTOR OF VETERINARY MEDICINE.

Signature*

Date*

Date

Informed Consent - Agreement, Indemnity, Release & Waiver

Initial*

I, the undersigned, warrant and certify that I am the owner or person responsible for my pet(s) brought to Jean Brusavich, CAMT, owner and founder of TranquilPET, Dog Swimming and Holistic Pet Care (hereafter referred to as Jean and TranquilPET).

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I understand that the services offered by Jean and TranquilPET are not intended as a substitute for veterinary care, and consultation with a veterinarian is required for any matters relating to the health of my pet(s). Further, I understand that individual sessions and corresponding outcome are dependent upon the condition and age of my pet, my goals, the nature of my pet’s injury (if applicable) and my pet’s emotional and behavioral condition. I understand that Jean and TranquilPET do not diagnose or treat injuries, illness or disease, nor does Jean prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations.

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I UNDERSTAND THAT ANY HOLISTIC APPROACH (DOG SWIMMING, ANIMAL MASSAGE, REIKI, ETC.) DO NOT TAKE THE PLACE OF PROPER VETERINARY CARE FROM A DOCTOR OF VETERINARY MEDICINE.

Initial*

I further agree that I am responsible for any risk posed by undisclosed medical conditions. I understand that by allowing my pet(s) to participate in the services offered by Jean and TranquilPET, I give my permission for Jean and TranquilPET to take photographs, and/or videos, and to use the images or videos of my pet(s) in printed matter, internet sites, or other promotional or advertising capacities. Photographs and videos are the property of Jean and TranquilPET.

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I accept full responsibility for any injury or damage, to persons, property or animals arising out of use of the grounds, facility, and pool, and the actions and conduct of the undersigned and my pet(s). Accordingly, I agree to indemnify Jean and TranquilPET for monetary damages and attorney fees; and further waive all personal claims and releases of Jean and TranquilPET, for damage, injury or death sustained by me, arising out of my participation in the activities and services of Jean and TranquilPET, or presence on or use of the premises where services are performed; and further waive subrogation claims of insurers. As a client of Jean and TranquilPET, I understand that my pet(s) and any person(s) I bring onto the property are at my own risk.

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It is my express intent that this Release and Hold Harmless Agreement shall also bind the members of my family and all respective heirs, executors, administrators, legal representatives, successors, and assigns, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above named RELEASES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of California.

By signing below, I acknowledge that I have read and fully understand this Informed Consent - Agreement, Indemnity, Release & Waiver.

Signature*

Date*

Date

Print Name*

First NameLast Name

Pet(s) Name*

Standard Terms & Conditions

Initial*

1. Disclaimer: You understand and agree that TranquilPET cannot, and does not, promise or guarantee any particular outcome for your dog by engaging in the Services. Each dog that TranquilPET services is unique, and, consequently, the outcome and results from the Services may vary from dog to dog. Further, all holistic modalities, including animal massage, Reiki, and canine aquatics, are not substitutes for proper veterinary care by a licensed veterinarian. Accordingly, you should seek out advice from your veterinarian for any injuries, illness, disease, or other medical or health concerns for your dog.

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2. Limitation of Liability.

In no event shall TranquilPET or its owners, employees, independent contractors, agents, or representatives be liable to you or to any third party for any consequential, incidental, indirect, exemplary, special, or punitive damages, whether arising out of breach of contract, tort (including negligence), strict liability, or otherwise, regardless of whether such damage was foreseeable and whether or not TranquilPET has been advised of the possibility of such damages, and notwithstanding the failure of any agreed or other remedy of its essential purpose.
In no event will the aggregate liability of TranquilPET or its owners, employees, independent contractors, agents, or representatives arising out of or related to these Terms, whether arising under or related to breach of contract, tort (including negligence), strict liability, or any other legal or equitable theory, exceed one (1) time the total amounts paid to ATCC under these Terms in the one (1) year period preceding the event giving rise to the claim. The foregoing limitations apply even if any remedy fails of its essential purpose.

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3. Governing Law; Jurisdiction; Venue. These Terms shall be construed, interpreted, and governed by the laws of the State of California Any claim or cause of action arising under these Terms or in connection with the Services may be brought only in the federal and state courts located in the County of Los Angeles, in the State of California; and you hereby consent to the exclusive jurisdiction of such courts.

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4. No Assignment. TranquilPET may assign these Terms without your consent in connection with the sale of all or substantially all of TranquilPET’s assets.

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5. No Modification/Waiver. These Terms shall not be modified or amended except by a further written document signed by you and the authorized representative of TranquilPET. A failure or delay in exercising any right, power, or privilege in respect of these Terms will not be presumed to operate as a waiver. No waiver of any rights under these Terms will be effective unless in writing and signed by the authorized representative of each of the parties. A waiver of any term or provision hereof shall not be construed as a waiver of any other term or provision hereof.

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6. Binding Effect on Successors. These Terms will be binding on and inure to the benefit of both you and TranquilPET to these Terms, and their heirs, executors, administrators, personal representatives, successors, and assigns, except as otherwise provided in these Terms.

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7. No Third Party Beneficiaries. There are no third party beneficiaries to these Terms.

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8. Severability. If any part of these Terms is held to be invalid, void, illegal, or unenforceable, the remainder of these Terms shall nevertheless remain in full force and effect. If any provision is held illegal, void, invalid, or unenforceable with respect to particular circumstances, it shall nevertheless remain in full force and effect in all other circumstances.

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9. Counterparts. These Terms may be executed in one or more counterparts, including electronic and digital signatures or signatures by facsimile, each of which shall be an original as against any party who signed it, and all of which shall constitute one and the same document.

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10. Entire Agreement. These Terms constitute the entire agreement of the parties pertaining to the subject matter hereof and merges all prior negotiations and drafts of the parties with regard to the transactions contemplated herein.

TranquilPET

By: Jean Brusavich

Jean Brusavich
Owner

AGREED AND ACCEPTED

By signing these Terms, you represent that you have read these Terms in its entirety, or have had it read and explained to you in its entirety before signing it. You understand the terms of these Terms and agree that it shall apply throughout the course of your relationship with TranquilPET.

Signature*

Date*

Date

NEW CLIENT INTAKE FORM

OWNER INFORMATION:

YOUR DOG(S):

ANIMAL MASSAGE:

REIKI MEDITATION: