Your Name (required)
Address (required)
Phone (required)
Your Email (required)
How did you hear about me?
Name (required)
Species
Breed
Sex Male Female
Age
Spayed/Neutered? Yes No
Indoor/Outdoor/Both? Indoor Outdoor Both
Length of time animal has been with you?
Veterinarian Care
Who is your current veterinarian?
Date of last vet visit?
Vaccination Program
Which vaccines are given to your animal?
Frequency?
Date of last vaccination:
Type/Brand of Food?
Current medications/supplements (Including flea/tic/heartworm, other parasite medications):
Exercise program: (How is your animal exercised and how often?)
Please list people in your family:
Other people your animal frequently socializes with: (friends, trainers, sitters, etc.):
Other animals in your family: (Please list their type/breed and how long they've been with you)
Health history
Presenting issues/concerns (Physical, emotional, behavioral, etc. And please list how long each issue/concern has been presented):
Were there any unique circumstances or transitions occurring in your animals life when problems first presented? Yes No If so, please explain:
Have you tried to resolve these issues through other means? Yes No If so, please explain:
How would your characterize your animals:
What is the demeanor of your animal?
How is your animal with unfamiliar people?
How is your animal with unfamiliar animals?
Any places on the body your animal guards/has sensitivity/does not like to be touched?
Anything else you would like me to know?
I understand that the BodyTalk session provided by this Certified BodyTalk Practitioner for my animal is intended to enhance relaxation, increase communication within the areas of the body, and to educate me to possible energetic or emotional blocks that may be creating pain, discomfort or disease for my animal.
BodyTalk is non-invasive, safe and objective. It utilizes the body's own innate intelligence to reestablish communication within itself.
I understand that BodyTalk is not a substitute for veterinary care or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease nor does the the Practitioner prescribe medications. I understand the BodyTalk Practitioner strongly recommends immediate veterinarian attention for any physically based conditions with my animal.
I understand that participation in a BodyTalk session for my animal is voluntary and that at all times I may choose to end our participation. I understand that the safety and care of my animal is ultimately my responsibility.
I agree to pay a fee per session. Payment is due at time of service. Since time has been especially reserved for me, I understand that a 24-hour cancellation is required to avoid charges for my scheduled session.
If I have any questions or concerns, I will address these promptly with the BodyTalk Practitioner.
By submitting this electronic form, I hereby agree to the above and authorize the Certified BodyTalk Practitioner to provide my animal with BodyTalk sessions.
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