Massage Therapy Client Intake

Client Intake Form

All information is held in strictest confidence. At no given point is information disclosed or shared without the client’s written consent.
Today's date*

MonthDayYear
Date
Full Name*

First NameLast Name
Cell Phone Number*
E-mail*
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Barn Address (where your horse lives) *

Street Address

Barn Name

CityState

Zip Code
Horse Information
Horse's Barn Name*
Horse's Registered Name
Horse Gender*

MareGeldingStallion
Age*
Breed
Estimated Weight
Color
Horse Health History
Does your horse currently have any physical/performance limitations?*
Examples: Not allowed to jump. Walk-trot only. Won't take left lead canter.
Currently, does your horse have any injuries or physical/performance limitations?
Enter injury diagnosis, date, and by whom diagnosed the injury.
Injury History
Enter injury diagnosis, date, and by whom diagnosed injury.
Surgery History
Enter type and date of surgery.
3. X-ray/ultrasound history
Enter type of imaging and date completed.
6. Has this area ever been injured this area before?*
10. Is there anything specific that creates, increases or decreases the issue? *
8. List all related treatments received for this injury.
Was the treatment used effective?
Yes/No and why or why not.
Goals of Therapy
Has the horse ever received a therapeutic massage?
Below are a few of the benefits of equine massage. What are your top 3 goals for scheduling a massage for your horse?*

General comfort/relaxationInjury preventionInjury rehabEnhance circulationImprove muscle tensionIncreased flexibility & range of motionAiding in muscle recoveryOther
Please list exercise and stress reduction activities (including frequency).*
Is your horse currently under other medical care besides general wellness care?
Chiropractors, PEMF, veterinary, physio, injections, etc.
Please check any areas that do or have caused pain or stiffness on your horse:
Left Side of Horse

HeadPollNeckFront leg / shoulderWither / Saddle areaStifleHockHind leg
Right Side of Horse

HeadPollNeckFront leg / shoulderWither / Saddle areaStifleHockHind leg
Please describe in more detail, and mark on horse below:
If you are on a mobile and can't mark below, please describe as best you can.
Are you okay with anti-static spray (usually a product like Cowboy Magic Supershine Spray) being used on your horse before and during the massage?*

YesNo
Are you okay with using essential oils on your horse during the massage? Before usage, type and purpose will be discussed with you.*

YesNo
Policies:
- Client services and chart information are confidential. Written authorization is required from you to release any information.
- Please turn off your cell phone for optimal relaxation for your horse.
- Please reschedule your session if you will be more than 15 minutes late.
- Your horse should be groomed, dry, and in a location where they are easy to access.
- A 24-hour cancellation notice is required to avoid being charged for your session.
- I understand that my therapeutic massage therapist or I may end the session at any time for any reason.
By signing below, I agree to all policies listed above.
Today's Date
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty:

Horse Information

Horse Health History

Goals of Therapy

Please check any areas that do or have caused pain or stiffness on your horse: