<p>Heavenly Spa Client Information</p><p>People Name(s): </p><p>Mailing Address: </p><p>City: State: WA Zip: </p><p>Home Phone: Work: </p><p>Cell Phone: Email: </p><p>ANIMAL INFORMATION:</p><p>Name(s): Breed: </p><p>Birthdate: ______Age: Sex: M / F Spayed / Neutered / Unaltered</p><p>Name(s): Breed: </p><p>Birthdate: ______Age: Sex: M / F Spayed / Neutered / Unaltered</p><p>Name(s): Breed: </p><p>Birthdate: ______Age: Sex: M / F Spayed / Neutered / Unaltered</p><p>MEDICAL INFORMATION:</p><p>Veterinarian Name/Address: </p><p>Surgeon Name/Address (if applicable): </p><p>Were you referred by your vet/surgeon? Yes / No </p><p>If Yes, why? If No, how did you hear about us?______</p><p>May we exchange information about your pet with your veterinarian? Yes / No</p><p>Is your dog on medication? Yes / No If yes, type of medication: </p><p>Please describe any problems or issues you pet may have: </p><p>How long has this been a problem/issue? see other side → GENERAL INFORMATION:</p><p>What does your dog’s diet consist of? </p><p>Does your dog like water? Yes / No If no, please explain: </p><p>What type of exercise does your dog get? </p><p>What level of training has your dog received? Basic / Advanced / Specialized: </p><p>Is there any other information you would like us to know about your dog?</p><p>SPA RULES 1.) You are responsible for your dog. 2.) All dogs MUST be on a leash at all times outside the gate area. 3.) As a courtesy to other clients, please wait for the previous client to get their dog in their car before coming into the gated spa area. You are welcome to walk your dogs outside the gate on the grounds, on leash. 4.) Please pick up after your dog. Bags are provided for your convenience and may be disposed of in the covered trash cans. 5.) Please close all gates behind you. 6.) Heavenly Spa has a 24-hour cancellation policy. If you cannot make your appointment, please cancel at least 24-hours in advance to avoid charges.</p><p>ACKNOWLEDGEMENT AND ASSUMPTION OF RISK</p><p>I hereby acknowledge that swimming, wading, or other physical exercise in or around the Hydrotherapy Pool at Heavenly Spa could cause physical harm to me or to my dog. I voluntarily participate in these activities and assume all risk of physical harm that might result to me or my dog. I represent that my dog and I are fully capable of participating in these activities without causing harm to either of us or to others. I acknowledge that the staff of Heavenly Spa is, and has been available to answer questions about the nature and physical demands of these activities and the risks, hazards, and dangers associated with them. I understand that the presence of Heavenly Spa personnel is absolutely no assurance of my safety, the safety of my dog, or the reduction of any of these risks. </p><p>RELEASE AND INDEMNITY AGREEMENT</p><p>I agree to release and covenant not to sue Heavenly Spa, with respect to all claims, liabilities, suits or expenses (including attorney fees and costs), arising out of any injury, damage or other loss to me or my dog in any way connected with my use or my dog’s use of Heavenly Spa’s facilities or participation in its programs.</p><p>______Printed Name</p><p>______Signature Dated</p><p>Thank you for choosing Heavenly Spa for your canine warm water healing needs!</p>