New Client Appointment Request Form - Animal Bodywork and Aromatherapy

*Important: Thank you for your interest in my animal bodywork and wellness services. Please complete the form below and you will be contacted to schedule an appointment. Dogs are seen in the Keyport office on Wednesdays and Fridays. Horses will be seen at the barn, based on my schedule in your area, on Mondays, Tuesdays, and Thursdays. I am not able to accommodate home visits for dogs at this time.

*Please note it is only necessary to provide one form per owner. Multiple animals may be listed below. If you have any difficulty please email Heather at info{at}animalbodywork{dot}com.

Name *

First

Last

Phone *

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Species

I am interested in:

Massage Therapy (Trigger Point, Sports Massage, Acupressure, Lymphatic Drainage, Myofascial Release)
Craniosacral Therapy
Horse and Rider Saddle Fit Evaluation
Aromatherapy
Thermal Imaging
Cold Laser Therapy
Equine Rehabilitation

What are your goals?

Consent and Waiver *

I agree

I understand that massage/ aromatherapy/ acupuncture work is not a substitute for medical treatment or medications, and that it is recommended that I work with my veterinarian for any medical conditions that my animal may have. I understand that Heather Wallace, or other non-veterinary associates of Animal Bodywork and Aromatherapy cannot diagnose illness or prescribe medications. I understand that any information provided by the therapist is for educational purposes only, and is not diagnostically prescriptive in nature. I have listed all my animal’s known physical conditions, limitations, medical conditions and medications. It is my responsibility to update this information with the therapist and contact my veterinarian if my animal’s physical condition, limitations, medical condition or medications should change. By signing this release, I consent to treatment for my animal and hereby release Heather Wallace, ESMT, CST, CCMT, CEE and the independent contractors of Animal Bodywork & Aromatherapy from any and all liability, past, present and future, relating to the bodywork services provided at your request.

Social Media Consent

I agree

I hereby give Heather Wallace/Animal Bodywork and Aromatherapy permission to photograph my animal for the purposes of posting on social media channels for promotional or educational purposes. I understand my personal information will remain private and will not be shared to the public with the exception of my animal’s first name and image.

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