New Client Form | Portland Animal Mass

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(971)-361-6097

Portland Animal Massage

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New Client Health Intake Form

Please complete and submit this when scheduling your fur baby's first appointment.

Guardian's Name(s):

Companion Animal's Name:

Email:

Phone

Address:

Age:

Male or Female?

Male

Female

Breed:

Color/Markings:

Are they Spayed or Neutered?

Yes

No

Name of Veterinarian:

Veterinarian's Phone Number:

May I contact your veterinarian with any questions?

Yes

No

Has your Companion Animal had massage, acupressure, or acupuncture before?

Yes

No

If yes, where and when was the last time?

Please list any medical issues or concerns they have:

Is your Companion Animal experiencing any problems with daily activities?

Yes

No

Unsure

If yes, please explain:

Is your Companion Animal involved in any competition or sports?

Yes

No

If yes, what type and how often?

Please tell me about your companion animal's likes or dislikes in terms of touch, food, toys, noise, etc:

When did your companion animal join your family and at what age?

Are there other animals in your home? Does everyone get along?

Are there any current behavioral or aggression issues?

Yes

No

If yes, please explain:

How did you hear about Portland Animal Massage?

I understand that massage and acupressure are never a replacement for veterinary care or treatment.

I understand that Lori Alexander, CAMT, will not: diagnose or prescribe treatment, attempt any adjustments/musculoskeletal manipulations, or prescribe any supplements or medications for my companion animal.

Today's Date:

Please Sign:

Thanks for submitting!

We can't wait to meet your fur-baby!

Phone

(971)-361-6097

E-mail

lori@portlandanimalmassage.com

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