Elizabeth Fey, CPMP Mailing Address: P. O Elizabeth Fey, CPMP Mailing Address: P.O. Box 211 Bradford Woods, PA 15015 Elizabeth@EaseAnimalMassage.com www.EaseAnimalMassage.com 412-491-9370 We are pleased to welcome you to our practice. In order to maximize your pet massage experience, please take a few minutes to fill out this form and we will review it during your first session. We look forward to working with you and your pet. Pet Massage is not, nor is it intended to be a substitute for traditional veterinary care, if necessary; and upon your request we will be happy to work with your preferred vet to discuss your pet’s special needs. Owner / Care Giver Information Name: Street Address: Email: City: Cell / Home Number Pet Information Pet’s Name: Species: Breed: Age / Birthdate Color Markings Gender: Primary Reason for massage: (30-60 mins*) Overall Wellness Athlete Geriatric/Arthritis Pre/Post Surgery Socialization Pre/Post Surgery List any sensitive areas: * Duration is dependent on your pet’s level of comfort Pet’s Health and Wellness Information Veterinary Hospital / Clinic: Phone Number Preferred Doctor: Surgeries (Circle) Yes / No if Yes please describe: Family Pet Rescue Pet Spay or Neutered (Circle) Yes / No Taking any Medication ( Circle) Yes / No if Yes, please list: Name of Kennel / Daycare: Please Check all that apply to your pet Service Pet Multiple Pet HH Outdoor (primary) Hunt Agility competition Certified Therapy Pet