* Required Field

* Date:
* Your First and Last Name:
* Mailing Address
* Home Phone:
Mobile Phone:
* Email Address:
* Animal’s Name:
* Type of animal (i.e. dog, cat, etc.)
* Breed:
* Gender: Male
* Age:
* How long have you had this animal?:
Name of your veterinarian:
Please check any of the following that apply to your animal: Has a serious illness, trauma, or surgery now or in the past
Currently is ill or recovering from recent surgery, bone fracture or illness
Has exhibited aggression toward humans or other animals
Has specific areas of the body that are sensitive or reacts to being touched
Any additional comments or information you would like to share about your animal or its problem:
* Medical Disclosure: Energy healing is not medical treatment & does not replace appropriate veterinary medical care by a licensed vet. Energy therapists do not diagnose or treat medical conditions & will not interfere with treatment by licensed professionals. Energy healing is used only to balance energy fields of the body. While these treatments may enhance healing, it is the client’s full responsibility to seek & use veterinary medical care as he/she would do without holistic complementary practices. I have read and understand the medical disclosure stated here.