Equine Intake Form 2021 with Release

Owner Name:*
Owner Address:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YESNO
Email*
example@example.com
Horses Name:*
Age:
MareGeldingStallion
Weight:
Breed:
Height:
Color:
Current Veterinarian:
What is your horse's current feeding program (including any medications, nutraceuticals, or supplements)?
Please describe your horse's housing (stall, turnout, etc.).
What is your horse mainly used for?
When was your horse last shod or trimmed?
When was your horse’s teeth last addressed?
When was your horse last vaccinated?
When was the saddle & tack last checked?
When was your horse last wormed & with what?
When was the last time your horse was seen by a vet and why?
Other than your vet, is your horse under the care of any other equine health care professional(s), such as an acupuncturist, chiropractor, homeopath, other body worker, etc.?
What are your goals for your horse (in training, competing, health, etc?
Is this session intended as part of your horse’s well-being protocol or do you have specific concerns and areas you would like to address?
PregnantLaminitisGastric ulcersNavicularGirthed/Cinched upFrequent colicEye ProblemsGroomed over backOpen woundsEar ProblemsTouched near sheath/uddersSkin disorderHip ProblemsGrooming over ribs/barrelNewly healed wound Leg ProblemsTouchy around earsArea of scar tissueHeart ProblemsDifficulty bridlingTeeth Issues
Recurrent LamenessCancerDifficulty bending (L or R)Nerve damageInability to collectAllergiesInability to pick up correct leadHistory of abuseUndiagnosed lumpDisc/Vertebrae ProblemsJoint pain/Arthritis/SwellingHas/does set back when tiedInfectious disease last 6 months
If you marked yes to any of the above please explain:
I am allowing my horse to receive massage therapy. I understand that massage is not a substitute for medical treatment or medications, and that it is recommended that I work with my Veterinarian for any medical conditions that my animal may have.
- OWNER/GUARDIAN HAS BEEN NOTIFIED THAT EQUINE MASSAGE THERAPY/COLD LASER THERAPY/CORE MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY ARE NOT SUBSTITUTES FOR VETERINARY CARE/MEDICINE. THEY DO NOT DIAGNOSE; IF YOUR HORSE APPEARS TO BE ILL, OR INJURED, PLEASE CONTACT YOUR VETERINARIAN IMMEDIATELY.
- PAYMENT IS NOT MADE AT THIS TIME, THERE WILL BE NO SERVICE PROVIDED. THERE ARE ABSOLUTELY NO EXCEPTIONS TO THIS POLICY.
- A 24 HOUR CANCELLATION POLICY. APPOINTMENTS MUST BE CANCELLED WITHIN 24 HOURS OF THE SCHEDULED MEETING; OTHERWISE, CLIENTS WILL BE CHARGED $40 FEE FOR SERVICES. EXCEPTIONS CAN BE MADE TO THIS POLICY.
- THE PERMISSION TO PERFORM EQUINE MASSAGE THERAPY/COLD LASER THERAPY/CORE MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY INTERVENTION ON HIS/HER HORSE TODAY AND ON ALL FUTURE DATES.
- INJURY ARISING OUT OF, OR RESULTING FROM, PARTICIPATION IN EQUINE MASSAGE THERAPY/COLD LASER THERAPY/CORE MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY, INCLUDING ANY NEGLIGENT ACTS.
- D.B.A. REILY EQUINE MASSAGE, LLC FROM ANY LOSS, DAMAGE, LIABILITY, OR INJURY, HOWEVER, CAUSED, RESULTING DIRECTLY OR INDIRECTLY FROM HIS/HER PARTICIPATION, OR FROM ACTS OR OMISSIONS. HORSE OWNER/GUARDIAN ACKNOWLEDGES THAT ACTIVITIES WITH AND AROUND HORSES INVOLVE INHERENT RISKS OF PHYSICAL INJURY TO PARTICIPANTS, HORSES AND TO OTHERS WHICH HORSE OWNER/GUARDIAN UNDERSTANDS AND EXPRESSLY ASSUMES.
The undersigned hereby execute and deliver this agreement. I hereby state UNDER THE PAINS AND PENALTIES OF PERJURY that I have read this INFORMED CONSENT FORM/RELEASE OF LIABILITY in complete detail, understand the consequences thereof, and execute this instrument as a sealed instrument this
blanks* day ofblank* ,2021
Name*

First NameLast Name
Signature*

Clear
Photography Release

This is optional, but would be greatly appreciated!!
I hereby grant CEILA J. REILY D.B.A. REILY EQUINE MASSAGE, LLC, the right to take photographs and videos of me and my property (i.e. horse) in connection with the above identified subject. I authorize CEILA J. REILY D.B.A. REILY EQUINE MASSAGE, LLC, its assigns and transfers to copyright, use and publish the same in print and/or electronically. I agree that CEILA J. REILY D.B.A. REILY EQUINE MASSAGE, LLC may use such photographs and videos of me and or my property (i.e. horse) with or without my name and for any lawful purposes, including but not limited to publicity, illustration, advertising, and web content.
(SIGN NAME)

Clear
Date

MonthDayYear
Date
Horse's Location if different then address above:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Photography Release