Student Clinic Intake Form

Pet Parent(s) Information
Name *
Name
Address *
Address
Phone *
Phone
Pet Profile
Neutered/Spayed? *
Veterinarian Phone
Veterinarian Phone
Has the pet had behavior training? *
Is this a shelter or foster pet? *
Is the pet comfortable with touch? *
Does the pet resource guard any of the following? *
Please check all that apply
Is the animal reactive to any of the following: *
Please check all that apply
Health History
Please be as detailed and specific as possible
I understand that any Students, Graduates, and Faculty working for Chicago School of Canine Massage (CSCM) are not licensed veterinarians and do not diagnose, perform surgery, or prescribe medications. I also understand that muscle therapy and energy work is not a replacement for proper veterinary care and that any inquiries or diseases must be medically diagnosed and treated by a veterinarian and give permission for CSCM Students, Graduates, and Faculty to work on my pet. I further understand that a complete history is necessary for accurate treatment of any kind and that participation by the owner/handler is essential to achieving beneficial results. Further, I understand that CSCM Students, Graduates, and Faculty are not responsible for any damages to others or to any property caused by my dog. *
Date *
Date