Massage Therapy Client Intake

Client Intake Form

Soulworks Canine Massage values our clients privacy. We will not share your personal information. We do ask your permission to share and receive relative medical information with your pets primary care veterinarian.*, **
Owners Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
Pets name*

First NameLast Name
Birth Date

MonthDayYear
Emergency Contact
Phone Number
Breed*
Weight*
Color
Medical Information
Veterinarian Information*

Veterinarian/Practice Name

Street Address

CityState / Province

Postal / Zip Code
Veterinarian Phone Number

Area CodePhone Number
1. List any injuries, illnesses, allergies or surgeries.*
2. List All medications and supplements your pet is currently taking.*
3. Explain any areas of concern.
4. Is your pet being treated by a health care professional for any conditions?
5. What activities does your pet enjoy?
Please check any areas that seem to cause discomfort or pain for your pet. Indicate right or left when applicable:
Neck

StiffnessPainful upon touchLimited movementDiagnosed disc herniationAny SwellingInjury Diagnosed by your veterinarian
Shoulders

Pain in shoulderLimited movementDiagnosed ArthritisAny SwellingInjury Diagnosed by your veterinarian
Fore limbs

Pain in upper limbSore jointsAny SwellingDiagnosed injury or disease by your veterinarianPain in lower limb
Back

Mid-back painPain between shoulder bladesPain up/down back
Low back painPain up/down low backDiagnosed disc herniationDiagnosed injury or disc disease by your Veterinarian
Hip

Pain on side of hipDifficulty risingDifficulty WalkingDiagnosed arthritisDiagnosed Hip DysplasiaDiagnosed injury or illness by your veterinarian
Hind legs

Pain in RIGHT legPain in LEFT legDiagnosed ArthritisDiagnosed CCL InjuryAny SwellingDiagnosed Injury or Disease by your veterinarian
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Payment is due at the beginning of each session.

       • Your scheduled session is set aside for your pet. We do not double book appointments.

  • 24 hour cancellation notice is required to avoid being charged for your session.

       • We will discuss any changes in your pets health, comfort or discomfort before each session and initial the form.

       • I understand that SoulWorks Canine Massage or I may end the session at any time for any reason

       • SoulWorks Canine Massage practices Fear Free handling and do our best to be respectful to your animals wishes. This promotes general wellbeing and reduces stress for everyone.

Client Agreement:

I understand that massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for Veterinary treatment or diagnosis, and it is recommended that your pet is examined and vaccinated yearly by your veterinarian.

SoulWorks Canine Massage will refer your pet to your veterinarian if there are any new areas of concern. I agree to let my veterinarian know about any new abnormalities that are found during my pets massage.

I have stated all my pets pertinent medical conditions, and will update Soulworks Canine Massage of any changes in my pets health status.

I understand that my failure to inform SoulWorks Canine Massage may pose a threat to my pets health and/physical well being and I hold harmless SoulWorks Canine Massage and my massage therapist from any liability whatsoever arising from failure on my part.

* I authorize SoulWorks Canine Massage to obtain current medical information from the above mentioned veterinary practice. This would include vaccine history, current medications ands treatments, and any recommendations or concerns your vet has regarding this pet.

** I authorize Soulworks Canine Massage to share massage treatment notes with the above mentioned veterinary practice.

By my electronic signature below, I agree to the policies and client agreement above.
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