Client Consultation Form
Owner
First Name
Last Name
Address
Street Address
Street Address Line 2
City
County
Postcode
Phone Number
-
Phone Number
Email
example@example.com
Preferred Method of Communication
Please Select
Email Only
Email and Hard Copy
Whatsapp
I consent to photos and videos being used for marketing purposes.
Yes
No
Vets Details
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
County
Postcode
Email
example@example.com
Dogs Details
Name
First Name
Breed
Age and DOB
Ownership as....
Puppy
Rehome
Length of time owned.
Gender
Please Select
Male
Female
Weight (if known)
What is your dog's job?
Pet
Working Dog
Therapy Dog
Does your dog have any veterinary diagnosed medical conditions?
Please Select
Yes
No
If yes, what are these?
If no, have they visited a vet for any other reason?
Any other health issues?
Current medications.
Does your dog have any other therapies?
Hydrotherapy
LASER therapy
TTouch
Acupuncture
Other
Has your dog had any accidents or injuries? This may include slips, trips or falls which did not involve a vet visit.
Dogs Lifestyle
How long/often do you walk your dog?
Do you walk your dog on a...
Neck collar
Head collar
Figure of 8
Slip lead
Short Lead
Long Line
Flexi Lead
Bungee Lead
How often is your dog off lead and for how long?
How does your dog interact with other dogs not from the same household.
Do you throw a ball for your dog?
Yes
No
Sometimes
Are you and your dog involved in any other sports.
Agility
Obedience
Canicross
Mantrailing
Working Trials
Any other comments or observations.
Dogs Environment
What type of surfaces does your dog walk on, inside and outside of the home?
Does your dog go up and down stairs?
How often does your dog get on and off furniture?
Are there other pets in the household?
If there are other dogs in the household how do they interact?
Are there any other relevant environmental details that should be shared?
Why are you considering myotherapy and what are your expectations?
Services Requested
Service
Muscle and Gait Assessment
Consultation and Treatment x 3 (Separate payments options available)
Maintenance Treatment
Signature
Submit
Submit
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