Grooming Registration

Has your dog been magnawaved by us before?

YesNo

New Magnawave Registration

We look forward to caring for your furbaby.
How did you find us?*

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Pet Owner's Information
Full Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Owner's Veterinary Provider

Name

Street Address

CityState / Province

Postal / Zip Code
Veterinarian's Phone Number*
Please enter a valid phone number.
Veterinarian's Email Address
example@example.com
Please provide your veterinarian's release form for us to perform Magnawave (PEMF):

Cancelof
Please provide vaccination card or invoice (or scan and email to info@circlelakeranch.com). We require Rabies (Annual or 3-year) Bordetella (6-month or annual), DHLP (annual or 3-year).

Cancelof
Pet Information
Pet's Name*
Breed
Age
Gender

MaleFemale
Spayed/Neutered

YesNo
Does your pet have any electronic implants such as pacemaker, intrathecal pump, etc?*

YesNo
Electronic implant details:
Is your pet currently receiving medical treatment?*

YesNo
Medical treatment details:
Does your dog have any of the following?*

Hot SpotsLumps Bumps or ScarsA recent CoughKennel Cough, influenza or contagious disease in the past 2 months?DiarrheaDiabetesArthritis/Hip Displaysia, Mobility IssuesBloat or GVDFleas/TicksSkin Infection or Open WoundItching or Hair LossVomiting in the past 48 hoursParvovirus in the past 6 montyhsEpilepsy or SeizuresHeart Disease or Heart MurmurAllergies (food or environmental)Eye discharge or rednessjEar Redness/Irritation/InfectionUrinary Tract Infection or IncontinencePregnancyImplantsNone of the Above
Medical Conditions / Allergies Details
Preferred Appointment Time
What are your goals for this Appointment:

Reduce InflammationEnhance RecoveryOverall WellnessOther
Additional Comments on appointment goals:
I understand that MagnaWave PEMF therapy is a non-medical, wellness modality and not intended to diagnose or treat disease. I confirm that all information provided is accurate, and I have consulted with or will consult with my veterinarian prior to treatment.
Date*

MonthDayYear
Date
Signature*

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Please note that there is a 3.5% fee applied to all credit/debit card purchases. We offer a cash/check discount.
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Returning Magnawave Customer

Welcome Back! We appreciate your business.
Pet Owner's Information
Full Name*

First NameLast Name
Phone Number if Changed
Please enter a valid phone number.
Alternate Phone Number if Changed
Please enter a valid phone number.
Pet's Name*
Does your pet have any new electronic implants such as pacemaker, intrathecal pump, etc?*

YesNo
Any New Medical Conditions / Allergies*
What are your goals for this Appointment:

Reduce InflammationEnhance RecoveryOverall WellnessOther
Additional comments on appointment goals:
Preferred Appointment Time
Please provide vaccination card or invoice (or scan and email to info@circlelakeranch.com) if your shot records need updating. We require Rabies (Annual or 3-year) Bordetella (6-month or annual), DHLP (annual or 3-year).

Cancelof
I understand that MagnaWave PEMF therapy is a non-medical, wellness modality and not intended to diagnose or treat disease. I confirm that all information provided is accurate, and I have consulted with or will consult with my veterinarian prior to treatment.
Date*

MonthDayYear
Date
Signature*

Powered by Jotform SignClear
Please note that there is a 3.5% fee applied to all credit/debit card purchases. We offer a cash/check discount.
Please verify that you are human*
Should be Empty:

New Magnawave Registration

Pet Owner's Information

Pet Information

Returning Magnawave Customer

Pet Owner's Information