Contact Info

To speak with me or to schedule an appointment, please call: 813.421.3152

For questions and general inquiries, please email: info@healingeffectsanimalmassage.com


New Clients:
In order for me to better serve your pet, a Health Intake Form for new clients will need to be completed prior to starting a session.
Please complete the form below or contact me for a printed version.

 





NEW CLIENT INFORMATION FORM

Pet Information

Pet’s Name (required)

Pet’s Species
CanineFelineOther
If other, please specify:

Pet’s Gender
MaleFemale

Pet’s Breed

Color/Markings

Pet’s Birth Date

Is the pet spayed/neutered?
YesNo

Owner Information

First Name (required)

Last Name (required)

Telephone Number (required)

Email Address (required)

Referred by / How did you find me?

Veterinarian and Health Information

Is the pet under the care of a veterinarian?
YesNo

Veterinarian / Clinic Name

Veterinarian / Clinic Phone Number

Is the pet up to date on vaccinations?
YesNo

Medications / Supplements Taken

Pet’s Diet / Food

Pet’s Stools

Pet’s level of daily activity
LowMediumHigh
Briefly describe the type of activity:

Please indicate any of the following conditions your pet currently has:
AllergiesCancerDiabetesHeart ProblemsFrequent UrinationAbnormal Skin ConditionArthritis / TendinitisNeck / Back InjuryJoint / Muscle SurgeryNumbnessMajor Accident(s)Recent Injury (please explain below)Other Conditions (please list below)Surgeries (please list below)

Please describe recent injuries or any conditions not listed above

Please list any surgeries with approximate dates

Does your pet have any difficulty lying on its front, back or side?
YesNo
If yes, please explain:

Do you feel your pet is currently under stress?
YesNo
If yes, please explain:

Is your pet nervous or aggressive around strangers or in strange places?
YesNo
If yes, please explain:

Is there a particular area where you think your pet is experiencing tension, stiffness, pain or other discomfort?
YesNo
If yes, please explain:

Has your pet ever had a massage?
YesNo
If yes, when?

Do you have any particular goals in mind for this/these massage session(s)?
YesNo
If yes, please list your goals:

Is there anything else about your pet or its health history that you think it would be useful for me to know?
YesNo
If yes, please explain:

By submitting this form, I acknowledge that I have read and agree to the following:

I have listed all of my pet’s known health conditions, including infectious diseases, and answered all questions honestly and I agree to inform the massage practitioner of any changes in my pet’s health between massage sessions.

I understand that the massage my pet receives is provided for the basic purpose of relaxation and relief of muscular tension and that the massage practitioner must be aware of any and all health conditions to provide safe and effective massage.

I understand that massage therapy is not a substitute for veterinary care and that the massage practitioner does not diagnose nor prescribe for injury, illness or any other physical disorder, nor does the massage practitioner treat any medical conditions in animals.

I understand that the massage practitioner is certified to provide massage for animals.

I agree to give 24-hour notice to cancel an appointment and I agree to pay the full fee for the session if I do not provide 24-hour notice to cancel.