Madison Canine Massage Waiver

Madison Canine Massage Waiver
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient name, age, breed
Patient major complaint? (What, where, when, how)
Can images of your pet be used for social media?
For Magnawave clients: if you are receiving Magnawave or holding your pet during the session:

You CANNOT have an implanted pacemaker or defibrillator or ANY implanted battery-operated device that you cannot remove.

Neither you or your pet can be pregnant or have had an organ transplant or have cancer.

You CANNOT have external screws/fixator.

Stents MUST be MRI compliant.
Signature Indicates the acknowledgment of risks and will not hold my therapist responsible for any omissions on this form. I understand massage, red light, Magnawave, cold laser and kinesiology taping services are designed to be a health aid only and is in no way a substitute for a Veterinarian’s care.

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