Animal Intake Questionnaire
Owner Information
Full Name
*
First Name
Last Name
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
How would you like to be contacted?
*
Text
Phone Call
Email
Address
Street Address
Street Address Line 2
City
Province
Postal Code
Additional Ownership Name & Contact Details
Farm Information (If Applicable)
Leave blank if not required.
Farm Name
Farm Address
Animal Information
Animal's Name
*
Age/Date of Birth
Sex
*
Please Select
Unaltered Female
Spayed Female
Lactating Female
Pregnant Female
Neutered Male
Intact Male
Species & Breed
Veterinarian
Medications (or none)
*
Any surgeries, screws, or plates? Please describe (or none)
*
Any health conditions? Please describe (or none)
*
If yes, what treatment/management is being done?
Any recent injuries? Please describe
Reason for PEMF/Red Light Therapy
*
Is there a special event for which you want therapy before or after? If so, briefly detail and include date.
Exercise/Activity Level and Frequency
Availability - Please let me know your preference for days/dates/time of day and I'll do my best to accommodate.
Legal
Please read carefully:
I understand that PEMF/Light therapy is not a replacement for medical care and no diagnoses will be made.
*
Yes
No
I understand that if I have a pacemaker, am pregnant, had an organ transplant, or have any kind of implanted device with a battery that cannot be removed I must remain at least 10 ft away from the PEMF machine during the session.
*
Yes
No
I understand that every animal responds differently, and that my animal may feel relaxed or tired in the day or days following a PEMF therapy session. This is a normal detoxification reaction. I will ensure they remain hydrated.
*
Yes
No
I acknowledge that there are potential risks associated with PEMF therapy, including but not limited to fatigue, discomfort, temporary changes in physical or mental state, and the possible exacerbation of pre-existing conditions. I assume all such risks willingly and knowingly
*
Yes
No
I hereby release and discharge MearaPulse Therapies, its practitioners, agents, and representatives, from any and all claims, liabilities, demands, actions, causes of action, costs, and expenses, whether at law or in equity, arising out of or in connection with my participation in PEMF therapy sessions.
*
Yes
No
I understand that fees owing must be paid within 30 days of services being performed or I will be subject to an interest of 10% added and compounded monthly.
*
Yes
No
(Optional) I consent to letting MearaPulse Therapies use photos of my animal on their social media and/or website, or for training purposes.
*
Yes
No
Legal Name
*
First Name
Last Name
Signature
*
Submit
Submit
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