Canine New Client Form – North Of 9 Equine & Canine Bodywork

Owner *

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Home Mailing Address *

Phone Number *

Email *

Co-Owner * If Applicable

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Phone Number

Home Address * If different than above

If Co-Owned-Do Both Owners Have Medical Signing Privileges?

If No, Who Has Signing Privileges?

Phone Number

Your Dogs's Name *

Your Dog's Show or Registered Name

What is your dog's breed?

Date Of Birth- Approximate year is fine *

Sex *

If Your Dog Is Intact, Are They Used For Breeding Purposes

Primary Veterinarian *

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Phone Number *

Additional Vet * If Applicable

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Phone Number

Please List Any Additional Canine Health Team Members And Details Below

Does your dog have any major medical history or current medical concerns? If yes, please describe below and not any current treatment plans and or medications ( including supplements) *

How would you best describe your dog’s personality, both with people and with other dogs? *

How Much Exercise Time Does Your Dog Get On Average Each Day? *

What does your dog currently eat? Include all supplements not listed above in medical history *

Do You Compete With Your Dog? *

If You Compete* How Often And Where Do You Travel?

What are the things that your dog currently does really well? *

What are the things that your dog currently struggles with? *

Is there anything else you would like to mention about your dog that we have not yet covered? If so feel free to use the space below. All details and questions are welcome- the more we know the more we can assist the body *

Informed Consent: I, the undersigned, do hereby acknowledge that I understand that the bodywork techniques used (Bowen, WEBB, Craniosacral, kinesiology tapings) used during my dog's session work to assist their body into a healthier state. I acknowledge that bodywork does not replace veterinary diagnosis or care. I agree to seek licensed veterinary care for any health concerns I have. I hereby voluntarily consent to having bodywork performed on my dog by the Certified Practitioners of North of 9 Equine & Canine Bodywork *

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Payment Agreement: I acknowledge that I have received and reviewed the current rates for my pet's bodywork session.I acknowledge that payment is due within 30 days of my billing date and subject to a late payment fee of $25 per month. Payment options include cash, e-transfer ([email protected]) or credit card (invoice link) *

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