New Client Intake Form Parent's Name *FirstLastSecond Parent's NameFirstLastEmail *Phone Number *Pet's Name *Species & Breed *Color *Weight *Age *Veterinarian *Veterinarian Phone NumberDate of Last Exam *Current Medications, Supplements, Herbal Remedies, or Essential Oils *Please include frequency and dose.Allergies including but not limited to medications, supplements, environmental, and food. Please describe reaction caused. *Does your pet have any known medical issues? Please include diagnosis or treatments, previous injuries or conditions, as well as surgeries and dates of procedures *Has your pet ever bitten anyone or shown human aggression? *yesnoExercise Habits *Sedentary - no exerciseMild Exercise - regular walks or activityOccasional Vigorous Activity - regular exercise or play or trainingRegular vigorous exercise - regular exercise or training 4-6x/weekPlease describe type of exercise activities. Include frequency and type of training, challenges in work, recent activity. *Describe your pets behavior. Include regular behavior and any observed changes in behavior or temperament and for how long. *Type of Pet Food *RawKibbleCanned FoodMixBrand and Amount of Food with Frequency given *Health Problems - Click if you have noticed any symptoms in the following areas. *SkinHead/NeckEarsNoseThroat/LungsChest/HeartBackIntestinal/ DigestionBladderGenitalsCirculationPosturePawsVisionHearingNone Please explain any significant symptoms checked above.Recent Changes *WeightEnergy LevelPerformancePain or DiscomfortNonePlease explain any changes checked above. *Is your pet receiving physical therapy for a condition? *YesNoIs your pet eating and drinking normally? *YesNoHas your pet ever received massage? *Yes - Doctor or Professional Massage TherapistYes - Pet parent or other (non-certified)NoDoes your pet adopt a specific posture? *YesNoDoes your pet favor one side when laying down? *Yes - RightYes - LeftNo Preference / AlternatesDoes your pet appear to sleep comfortably? *Yes NoYes - only at nightYes - only during the dayIs your pet confined? *YesNoIs your pet recently adopted or purchased? *YesNoDoes your pet require bandaging? *Yes NoDoes your pet require hydrotherapy? *Yes - MedicalYes - Fitness/Wellness ProgramNoPlease describe any of the above issues with "yes" marked as the answer. *Any helpful information about your pet. This may include eating, sleeping, or postural habits, favorite toy or treat, or anything else that may help us assess or get to know your pet better! (copy)How did you hear about us? *FacebookTwitterInternet SearchFriend or FamilyInstagramLocal EventI release Keki Holistics from any and all liabilities that may or may not occur as a result of receiving of pet massage. I understand Keki Holistics is not a veterinarian doctor and cannot treat, diagnose, or cure any pet illnesses or injuries. I understand by typing my name I am submitting an electronic signature.Signature: *Signature Date: *NameSubmit