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All Around Dogs

Wellness Center

Canine Swim Services,
Body Work for Small Animals &
Energy Work for All Animals

by cheri wildes

“Unleashing Wellness”

a steady companion brand

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Client Forms

Intake & Release Forms

Please Note: Release Forms and forms associated with appointment record-keeping are required as part of our Washington State Small Animal Massage Practitioner Licensing.

We would like to thank you in advance for your timely submission of these forms.

Form Instructions & Guidelines

Complete the following On-Line All Around Dogs Wellness New Client Intake Form to the best of your ability.
Choose Between Our On-line Form, Word or PDF Options.
Review and accept the Terms of Service, Consent & Release statement.
Submit the completed on-line form no later than 24 hours prior to your animal’s scheduled appointment.
- This allows sufficient time for us to review the form, and identify any follow-up questions in advance of your scheduled appointment.
We request your transparency in terms of any known medical conditions, behavior issues, etc.
- We work with intact animals, as well as animals with behavior challenges, bite histories, and fear of Veterinary situations.
- This will allow us to create a plan to work most effectively, and successfully, with you and your animal.
All questions pertaining to a recent illness, injury or surgery are to confirm your animal is no longer experiencing any contraindications, has the appropriate Veterinary release, and able to receive body or energy work services.
If your animal has been diagnosed with a chronic condition, we may require a release from your primary or Specialist Veterinarian prior to working with your animal.

Client Forms – On-Line Form

Client Intake & Terms of Service

Client Intake Form

Updates

Pet Owner's Information
Animal Client's Information
Veterinary Contact Information
Treatment Goals & Objectives
Pet's General Health & Lifestyle
Health History & Current or Past Issues
Terms of Service & Release of Liability

Pet Owner's Information

First Name

Last Name

Email

Primary Phone

Alternate Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Were You Referred to Us?

Yes

No

Referred By:

Animal Client's Information

Animal's Name

Species

Breed

Color

Sex

Altered?

Age

Weight in Pounds

Time with Current Owner

Upload Image of Your Animal

Choose File

Veterinary Contact Information

Veterinarian's First Name

Veterinarian's Last Name

Veterinary Clinic or Hospital

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Veterinarian's Phone

Veterinarian's Email

Can Copies of Veterinary Documents be Provided if Requested?

Yes

No

If No, Why?

Treatment Goals & Objectives

Goals & Objectives Owner Would Like to Achieve. Summarize primary complaints or issues:

List Owner’s Goals & Objectives: [Summarize primary objectives and goals for the session(s).]

Pet's General Health & Lifestyle

List information about general health, lifestyle (including activity level), diet/nutrition/supplements, etc.

Exercise/Activity Level: [List types and frequency of exercise. Include walks, event participation, dog park visits, etc.]

Diet /Appetite: [List type, amount, and frequency of meals including any eating habits. Include any treats if applicable.]

Is Animal Taking Any Supplements?

Yes

No

If Yes: [List all nutritional supplements, including dosage and frequency.]

Environmental Influences/Lifestyle: [List overall lifestyle including relationship with humans and other animals. Have there been any recent changes to their home life?]

Emotional History: [Summarize animal’s general emotional state. List any behavioral changes, recent or past trauma, history of abuse or biting?]

Health History & Current or Past Issues

Include any regular medications, current or past treatment, illnesses, injuries, surgeries, etc.:

Is Animal Up to Date on Shots or Have a Current Titer?

Yes

No

Is Animal Taking Any Medications?

Yes

No

If Yes: [List all medications, condition(s) being treated, dosage and frequency.]

Does Animal Have Any Joint/Orthopedic Issues?

Yes

No

If Yes: [List known orthopedic or joint issues.]

Does Animal Have Any Current or Past Injuries?

Yes

No

If Yes: [List any past, current or chronic injuries your animal has/is experiencing. Were they formally diagnosed by a Veterinarian?]

Has Animal Had Recent or Past Surgeries?

Yes

No

If Yes: [List any recent or past surgeries, the date and issue treated. Include spay or neuter date (if known/applicable). If recent, does animal have a Vet release approving body or energy work treatments, including swim therapy?]

Has Animal Had a Current or Past Illnesses?

Yes

No

If Yes: [List any past, current or chronic illnesses animal has/is experiencing. Were they formally diagnosed by a Veterinarian?]

Does Animal Have Current or Past X-Rays?

Yes

No

If Yes: [List any X-rays your pet has had to date and why. Include OFA clearances if applicable.]

Does Animal Have Current or Past Allergies?

Yes

No

If Yes: [List any past, current or chronic allergies animal has/is experiencing. Were they formally diagnosed by a Veterinarian?]

Does/Has Animal Experienced Other Treatments or Modalities?

Yes

No

If Yes: [List treatments animal has received to date including frequency. Have they had any bad experiences with body/energy work, swim therapy or Veterinary care?]

Additional Information: [List any diagnosed structural or genetic issues for the animal’s breed, e.g., TVD or other heart issues, or any past issues with Heartworm, Parvo or Distemper?]

If Swim Therapy or Swim Conditioning Client: Does dog have past swimming experience?

Yes

No

If, Yes Describe: [Do they actually swim, only wades, uses a life vest, likes to retrieve, etc.]

Terms of Service & Release of Liability

Disclosure Statement / Terms of Service:
I, Cheri Wildes, am not a Veterinarian. I do not diagnose or treat medical issues, wounds, injuries, offer medical advice, prescribe drugs, perform surgery or other mechanical therapies restricted to the field of Veterinary medicine. I also do not, adjust or manipulate the animal’s body or spine, or perform Acupuncture.

My role is that of a holistic Practitioner. My services are solely for the purposes of supporting the animal’s overall well-being, and to assist the animal to attain and maintain a naturally healthy state. The specific results of Body or Energy Work or Swim Therapy sessions will be different for each animal.

Release of Liability & Consent:
I have read and understand the above Disclosure Statement and Terms of Service regarding the services to be given to my animal(s) by Cheri Wildes of Steady Companion/All Around Dogs Canine Wellness.

I understand that Cheri Wildes is not a Veterinarian, that the services given are not to be considered as Veterinary medical treatment, and the comments, suggestions and recommendations offered during this service are not to be construed as Veterinary medical advice.

Body or Energy Work, including Swim Therapy, and other holistic modalities are not a substitute for Veterinary medical care, but rather a cooperative form of therapy.

I consent that I wish to have these services for my animal(s), and acknowledge I am agreeing in compliance with the Washington State Veterinary Practice Act.

I certify that my animal(s) have received regular Veterinary care and vaccinations, as needed.

I acknowledge that I have read and fully understand the previous statements and consent to Cheri Wildes of Steady Companion/All Around Dogs Canine Wellness performing Body & Energy Work or Swim Therapy Services or other holistic modalities as outlined above on my animal(s).

I understand by agreeing to these terms I am waiving any and all claims I may have against Cheri Wildes of Steady Companion/All Around Dogs Canine Wellness.

I have read and agree to the Terms & Conditions and Release of Liability.

Signature

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Client Forms – PDF & Word Versions

Client Intake & Terms of Service

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Client Intake Form

PDF Format

Access Form Here:

Client Intake Form

Type or Hand Write Responses Email to Address Provided on the Form Within 24 Hour of Scheduled Appointment.

i

Terms of Service Form

PDF Format

Access Form Here:

Terms of Service Form

Type or Hand Write Responses Email to Address Provided on the Form Within 24 Hour of Scheduled Appointment.



Client Intake Form

Word Format

Access Form Here:

Client Intake Form

Type or Hand Write Responses Email to Address Provided on the Form Within 24 Hour of Scheduled Appointment.

i

Terms of Service Form

Word Format

Access Form Here:

Terms of Service Form

Type or Hand Write Responses Email to Address Provided on the Form Within 24 Hour of Scheduled Appointment.

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Session Instructions

PDF Format

Access Form Here:

Session Instructions

Type or Hand Write Responses Email to Address Provided on the Form Within 24 Hour of Scheduled Appointment.

i

Policies & Guidelines

PDF Format

Access Form Here:

Policies & Guidelines

Type or Hand Write Responses Email to Address Provided on the Form Within 24 Hour of Scheduled Appointment.



Session Instructions

Word Format

Access Form Here:

Session Instructions

Type or Hand Write Responses Email to Address Provided on the Form Within 24 Hour of Scheduled Appointment.

i

Policies & Guidelines

Word Format

Access Form Here:

Policies & Guidelines

Type or Hand Write Responses Email to Address Provided on the Form Within 24 Hour of Scheduled Appointment.

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Monday: Closed
Tuesday: 11:00 am – 7:00 pm
Wednesday: 9:30 am – 5:30 pm
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