Client Intake Form- The Canine Comfort Club

Client Intake Form

Please complete this form to help us understand your dog's needs and provide the best care.
Section 1: Your Contact Information
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
District
Section 2: Your Dog's Information
Dog's Name
Age
Breed
Weight (kg)
Sex
Service Interest
Section 4: Health Status
Does your dog have any diagnosed medical conditions?
If yes, please describe the medical condition(s)
Is your dog currently taking any medication?
If yes, please list the medication(s)
Has your dog ever been diagnosed with cancer?
Date of last veterinary visit

MonthDayYear
Date
Veterinary clinic name
Veterinarian's name
Is there anything else you would like me to know?
Section 5: Declarations & Consent
Declaration
I understand that Wellness Massage is a relaxation service for healthy dogs and does not replace veterinary care. I understand that Prescribed Comfort Care requires a veterinary or physiotherapy referral and is provided under professional direction. My veterinarian or physiotherapist remains responsible for diagnosis, treatment, and medical decisions.
Data Privacy Statement
The personal data collected in this form will be used solely for the purpose of providing services through The Canine Comfort Club. Data will be kept confidential and secure. You have the right to request access to and correction of your personal data held by The Canine Comfort Club.
Section 9: Signature & Date
Date

MonthDayYear
Date
Signature (Type Full Name)
Should be Empty:

Client Intake Form

Section 1: Your Contact Information

Section 2: Your Dog's Information

Section 4: Health Status

Section 5: Declarations & Consent

Section 9: Signature & Date