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Dakara's Calming Essence for Pets
Flower Essence Blend

Fee for Custom Blend $39.95 plus flat rate shipping $6.00

  Dakara's Calming Essence for Pets Home || Dakara's Calming Essence for Pets Testimonials
Rescued Animal Support  ||  Suggested Usage || Personal Pet Blend || What are Flower Essences || Order 
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Please submit this questionnaire form with your order form

    Owner Name:________________________________   Animal/Pet Name:____________________________
    Address:____________________________________   Pet Age:____________
    City/ST/Zip:_________________________________   Specie:______________
    Phone:_____________________________________   Breed:______________________________
        Sex: M____ F____

    List specific behavioral problems or situations: (separate piece paper)
    When did they start:
    Has anything provoked the problem:
    Life style changes:
    Changes in household: (moves, death in family, etc.)
    Be as detailed as you feel necessary:
    What was animals behavior like before problem:
    (if you know the start)

    1. How did your animal friend come into your life?

    _____ A. Bought at a pet store   _____ E. Answered ad in paper
    _____ B. Gift from a friend   _____ F. From a breeder
    _____ C. Adopted from an animal shelter   _____ G. Picked up at grocery store
    _____ D. Found abandoned    

    If you marked 1C - How did the animal come into the shelter?
    Was there a history of abuse? YES / NO
    If yes, please explain:

    If you marked 1D - Where and how was the animal found?

    If you marked 1E - What was the reason for the animal to leave its current home?

    2. How old was your animal friend when you started your life together?

    3. Have you ever used Flower Essences on your animal friend before? YES / NO
    If yes, what type:
    For what purpose:
    Did you notice an improvement?

    4. Has your animal friend been spayed of neutered? YES / NO
    If yes, date if known:

    5. List any health conditions or concerns, include surgery dates if possible:

    6. List the type and name of the food your animal friend is currently eating

    Brand Name _____________________________ Canned/Dry/Pellet/Seed
    How often do you feed your friend? ___________ x per day.
    Prescribed by your Vet? YES / NO

    7. Do you give your animal friend vitamins or supplements? YES / NO
    If yes, what type?
    For what condition?

    8. Please check all that apply:
    __ Shock, trauma, illness, injury, surgery, emergencies
    __ Breaking undue emotional attachments to the caretaker, such as whining and moping dogs waiting for the owner to return
    __ Unknown fear or terror in animal
    __ Extreme tension or stress, such as a scared or frightened animal that is trapped
    __ Jealous pets, especially when jealousy involves another per vying for the attention of the caretaker
    __ Before and after a major move; helps to break links to old places of residence
    __ For nervous conditions in animals
    __ Excessive barking
    __ Encourages interspecies communication
    __ Confusion or being overwhelmed when traveling or when there is a change in schedule
    __ Animals giving birth
    __ Animal that bite
    __ Helping the body to use its own healing forces
    __ Lifting the spirits of an animal that is depressed due to illness or old age
    __ To help animals living together in a group or herd to adjust, especially when
    a new animal has been introduced or when a “group” animal become a single pet
    __ Shy
    __ Emotional upset, gas or vomiting
    __ Is your animal in training? YES NO
    __ Taken from mother to young?

    9. Does your animal friend live: INDOORS OUTDOORS BOTH

    10. How many hours in your animal friend left during the day? ___________

    11. Does your animal live with other animals? YES NO
    If yes, please list what types and their names:
    1. ___________________________
    2. ___________________________
    3. ___________________________


I the undersigned, understand that Flower Essences and Gem Elixirs are not a medical substitute for any physical ailments that I may have
a this time and that I have or will consult a Licensed Professional. I furthermore,
hold harmless Wendy Lloyd or DaKara Kies Company from any liability and I take complete responsibility
for my personal well being.

Signature: _________________________________

Date: ______________________________

To order via PayPal please click here


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DaKara Kies
Flower Essence Practitioner
P.O. Box 4338
Everett, WA 98204
(425) 267-9730 or (425) 953-4304


DaKara Kies Co. Holistic Products for Health


 Dakara's Calming Essence for Pets Home || Dakara's Calming Essence for Pets Testimonials
Rescued Animal Support  ||  Suggested Usage || Personal Pet Blend || What are Flower Essences || Order 

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