Client Information Form

Please fill out this client information form prior to your first water therapy appointment:

Dog's Name:	Age:	Breed:
Your Name:
Address:
City:	State:	Zip:
Phone:	E-mail:


VETERINARIAN INFORMATION
Regular Vet:		Phone:
Orthopedic:		Phone:
Chiropractor:		Phone:
Acupuncturist:		Phone:
Other:		Phone:
Other:		Phone:

Has your dog had a recent injury?
(If Yes, please describe below)

Has your dog had a recent surgery?
When? By Whom?

Please describe your understanding of the surgery, what side it was performed on, etc...

Please describe and list the dates of any other/older past injuries and surgeries.

How are you hoping that your dog will benefit from spa therapy?

Does your dog have any problems with bowel/bladder control?
(If Yes, please explain)

Please describe your beliefs about vaccinations and your vaccination schedule.

Please list methods, if any, that you use for flea control on your pet and at home.

(Please do not use topical flea/tick products on your pup within 5 days of your spa session. Studies have shown that these products can leach into the pool and onto your therapist! Thank you!)

Please describe your dog's home enviroment (Where/How does he spend the day? The night?)

Do you have children? What are their ages?

Do you have other dogs? If yes, what are their names, breeds and ages?

Please describe your dog's relationship with water?

Does your dog enjoy swimming after toys?
If yes, what type?

Does your dog enjoy being held and massaged?
Please write any comments below.

Please describe any emotional components of your canine friend that you would like me to be aware of so that I can better honor his/her boundaries and help him/her to be as comfortable and confident as possible during our sessions together.

What do you feed your dog?

Feeding Schedule?

What kind of treats does your friend enjoy?

If treats are given, how many and how often do you give them?

Please list supplements of any type that you give to your dog. Please list the supplement, how often given, reason given and by whom they were prescribed.

Please list any medications that you give to your dog. Please list the medication, how often given, reason given and by whom they were prescribed.

Therapy