New Client Consent Form

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What services are you interested in? *

Veterinary Orthopedic Manipulation (VOM)

Animal Neuro Myofascial Release (ANMR)

Cold Laser Therapy

Canine Osteopathy

Homeopathy

Muscle Testing

Other

Consent Agreement *

I acknowledge that VOM, massage, ANMR, homeopathy, and muscle testing are not substitutes for medical treatment or medications for my animal. It is advised that I collaborate with my veterinarian for any medical conditions my animal may have. Heather Elysium and other non-veterinary associates of Animal Bodywork and Homeopathy do not diagnose illness or prescribe medications. Any information provided by the therapist is solely for educational purposes and is not prescriptive. I have disclosed all known physical conditions, limitations, medical conditions, and medications of my animal, and it is my responsibility to update this information with the therapist and inform my veterinarian of any changes. By signing this release, I authorize treatment for my animal and release Heather Elysium, from any liability, past, present, or future, associated with the bodywork services provided upon my request.

I agree

Social Media and Website Consent *

I give Heather Elysium permission to photograph my animal for the purposes of posting on social media channels for promotional or educational purposes. I understand my personal information will remain private and will not be shared to the public with the exception of my animal’s first name and image.

I agree

I do not consent