WEBB Student History Form – North Of 9 Equine & Canine Bodywork

Owner *

First

Last

Home Address *

Phone Number *

Email *

Co-Owner * If Applicable

First

Last

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

Date Of Birth- Approximate year is fine *

Sex *

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

Primary Veterinarian *

First

Last

Phone Number *

Additional Vet * If Applicable

First

Last

Phone Number

Chiropractor *If Applicable

First

Last

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 WEBB for pets bodywork provides support to my dog's overall well being and is a hands on modality. 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 a Student WEBB Practitioner under the guidance of Certified WEBB Practitioner & Instructor Caren Dougall of North of 9 Equine & Canine Bodywork (CD EQ INVESTMENTS INC) *

First

Last