Doggy Details Form : Tell me about your best friend

Your Details

Let me know how I can contact you

First Name

Last Name

Email Address

Contact number

House number/name

Postal town

Postcode

Your Vet's Details

Tell me which Veterinary Surgery your dog is registered with

Name of Vet Practice

Branch/Town

Your Dog's Details

Tell me all about your dog

Name

Breed

Age (years)

Date of Birth (if known)

Age (months)

Gender

Female

Male

Neutered

Yes

No

Been with you since a puppy?

yes

no (please give details)

Details

Health

Tell me all about your dog's health

Please describe any significant accidents or injuries your dog has had

Please list any medications and/or supplements your dog is taking

I want to try Galen Myotherapy because

my dog has an underlying condition

my dog had, or is going to have, an operation

my dog is recovering from an injury

my dog is healthy and I want to maintain or improve that

other (please provide details below)

Details

Environment

Tell me all about where your dog lives and what activities they take part in

What activities do you take part in?

walks (mainly in town/on hard surfaces)

walks (mainly parks/woods/off pavements)

dog sports

playing with a ball

swimming

other

Floor surfaces at home and/or at dog sitter

carpet/rugs throughout

lino

laminate or solid wood

tiles

Where does your dog go in the house?

downstairs only

downstairs and upstairs

Any character change?

yes (please add details below)

no

% of time on the lead when walking

How many minutes on average does your dog exercise each day?

We use a

collar

harness

head collar

Multi dog household?

yes (please add details below)

no

Details

What 3 things do you hope Galen Myotherapy will achieve for your dog?

Anything else?

If there is anything you would like to tell me about your dog before we meet, or if you have any questions, here is the place to let me know!

Comments / Questions

I am happy for Ki5 Canine Therapy to use any photos or videos of my dog taken during consultation and treatment for (choose all that apply)

for internal training purposes (other Galen Myotherapists)

for the Ki5 Canine Therapy website

for Ki5 Canine Therapy social media (Facebook & Instagram)

for external training purposes (delivering workshops/presentations)

Declaration

I agree to Ki5 Canine Therapy's terms and conditions https://ki5canine.co.uk/terms-and-conditions/

I confirm that I am the legal owner of the above mentioned dog

I confirm that all information provided on this form is correct to the best of my knowledge