Animal Bodywork and AromatherapyNew Client Form

Owner Name *

First

Last

Email *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Animal Name *

Gender

Species *

If other, please specify species:

Breed (All breeds welcome, for our records only)

Age

Barn Name/Address (where appointment will take place if other than office.)

Medical History

Veterinarian Name *

Did you veterinarian refer you?

If no to the above, how did you hear about our services?

What is your primary goal for your animal? How can we best help you?

Medical History *

Please list any chronic illnesses, lamenesses, allergies, or past surgeries.

Has your animal had bodywork previously?

Yes
No
I'm not sure

Bodywork

I am interested in the following services.

Therapeutic Massage/ Cold Laser Therapy
Aromatherapy (includes customized blend)
Craniosacral therapy
Horse & Rider Saddle Fit Evaluation
Concierge Acupuncture (Home/Barn visits)

*Please note thermal imaging is included in initial massage sessions upon request but may also be provided a la carte for farrier/veterinary purposes.

For our safety

Please indicate any sensitive areas or behavioral triggers we should be aware of during bodywork.

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.

Consent and Waiver *

I agree

I understand that massage/ aromatherapy/ acupuncture/chiropractic 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.

New Client Form

Medical History

Bodywork

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