INTAKE FORM

Initial Intake Form & Liability Waiver

Date *

Month Day Year

Name of Horse Owner *

First Name Last Name

I understand that equine massage therapy services offered by Vitality Equine are never a replacement for proper veterinary care. Signs of lameness or illness are contraindications to equine massage therapy. I understand that if my horse is showing any signs of lameness or illness, Vitality Equine cannot proceed with body work until it has been cleared by a veterinarian. I understand that the Vitality Equine practitioner will not diagnose conditions, attempt any adjustments/musculoskeletal manipulations or prescribe medications, nutraceuticals or supplements for my horse. If my horse is currently being seen by a veterinarian, I have cleared this work with the attending veterinarian to ensure body work is at this time is appropriate for the horse. I acknowledge that muscle releases may result in underlying muscle mechanisms being exposed that were previously masked through compensatory movements.

By signing this document I acknowledge that I have read and understand it and all of its provisions and I am signing voluntarily. I do hereby waive and release Vitality Equine from all liability, past, present and future.

Signature

Clear

Client Information

Name of Horse Owner *

First Name Last Name

Phone Number *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail *

Preferred Method of Contact: *

How did you find out about Vitality Equine?

Name of Referral (if applicable)

Would you like to receive news and promotions from Vitality Equine?

Equine Information

Name of Equine Athlete *

Barn Name Registered Name (if applicable)

Name of Equine Barn

Veterinarian

Farrier

Chiropractor

Trainer

Discipline

How long have you owned this horse?

Breed?

Sex?

Age?

Colour?

Height?

Equine History & Health Information

Describe your training/conditioning program: *

What are your goals for this horse? *

Are there any personality traits or vices Vitality Equine should be aware before the session(i.e. cribber, nippy, anxious when alone, sensitivities…etc): *

When was the last time your horse was seen by a veterinarian, and why?: *

Is your horse on any current medications, nutraceuticals or supplements?: *

When was your horse last vaccinated and/or wormed?: *

What is your horse’s feeding program?: *

What is the current housing and turnout schedule for your horse?: *

When were your horse’s teeth were last addressed?: *

Is this massage session intended as part of your horse’s well-being protocol or do you have specific concerns/areas you would like addressed?: *