Animal Intake Form ~ Reiki Owner Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Is the animal located at the above address? Yes No If no, address of animal: Animal Name * Animal species: * Dog Cat Avian Pocket Pet Livestock Exotic Breed: Spayed/Neutered? * Yes No Age: * Under 1 year 1-4 years 5-9 years 10+ years Where did you acquire the animal? Breeder Shelter/Rescue Friend/Relative Other Is the animal under the care of a Veterinarian? * Yes No If "Yes" please describe: Veterinarian Information: First Name Last Name Phone (###) ### #### Please describe reason for seeking services: * My animal can be described as: * Friendly Shy Fearful Reactive Aggressive Is the animal sensitive to touch? * Yes No If "Yes" please describe: Does the animal have any allergies/sensitivities? * Yes No If "Yes" please describe: How did you hear about me? Web Search Friend/Relative Veterinarian Social Media Other Do you consent to photo's/video of your animal(s) receiving Reiki being posted on the Birch Wellness Center social media page and/or website? * Yes No Thank you for taking the time to provide this valuable information on your animal. All information provided is safe and confidential.I look forward to meeting you and your animal and assisting in their wellness journey.
