~~Intake

A Balanced Pup

Canine Massage Therapy
Owner's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Date

MonthDayYear
Veterinarian (Name and phone number)
Pets Name
Pet's DOB

MonthDayYear
Breed
Sex

MaleFemaleMale NeuteredFemale Spayed
Weight (lbs.)
Vaccinations

RabiesDAPPLeptospirosisCanine Influenza VirusBordetellaLyme disease
Can I give the animal treats? (If yes, what type?)
Is there anything that the animal likes or dislikes in terms of touch, food, toys, noise etc...?
Where did you obtain your animal companion?
Other animal companions in the home? (Type, How Many?)
Current Medications
Major Complaints
Current Symptoms?
What are you looking to achieve?

Pain ReliefRelaxationImprove circulationDrain lymph fluidImprove Muscle ToneImprove FlexibilityImprove Range of MotionReduce swelling and edema
Has your animal received a massage before? (If yes, state date and purpose)
Is the animal sensitive to touch/pressure? (If yes, where?)
What do you feed your animal companion?
Any current/specific behavioral problems? (If yes, what?)
How often is your pet groomed/bathed?
Any surgeries (besides spay/neuter)? If yes, specify when and type of surgery.
Is there anything else that I should know about your animal companion?
MASSAGE DOES NOT TAKE THE PLACE OF PROPER VETERINARY CARE FROM A DOCTOR OF VETERINARY MEDICINE. PLEASE CONTACT YOUR LOCAL VETERINARIAN FOR ANY PERSISTENT PROBLEMS BOTHERING YOUR ANIMAL COMPANION.
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A Balanced Pup