Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number *

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Pet's Date of Birth (or approximate if unknown) *

MM

DD

YYYY

Gender *

Female

Male

Veterinarian's Phone *

(###)

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I understand Erin Kowalski and Lindsey Gavel are not licensed veterinarians and do not diagnose, perform surgery, or prescribe medications. I also understand that muscle therapy and energy work are complementary modalities and that any injuries or diseases must be medically diagnosed by a veterinarian. I authorize Erin Kowalski and/or Lindsey Gavel to use the recommended rehabilitative treatments on my pet as referred by my veterinarian. I further understand that a complete history is necessary for accurate treatment of any kind and that participation by the owner/handler may be necessary and veterinary referral for recommended treatment does not constitute a guarantee of results. I waive and release any and all rights, claims and causes of action I have or may have against Erin Kowalski, Lindsey Gavel, Wild Hearts and their affiliates, officers, directors, employees, representatives, that may arise as a result of any recommendations or treatment of my pet. Further, I understand that Erin Kowalski and/or Lindsey Gavel is not responsible for any damages to others or to any property caused by my pet. I understand that payment is due in full at the time of treatment and that appointments not cancelled at least 24 hours in advance will be billed at half the standard fee. *

I agree.

I do not agree.

Photographs and videos for purpose of education, promotion and advertising may be taken. Please select one of the following: *

I authorize the use of my pet's image or likeness for the above purposes.

I do not authorize the use of my pet's image or likeness for the above purposes.

Date *

MM

DD

YYYY