New EQUINE Client Intake Form

Name

First NameLast Name
Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Barn/Ranch Address (if the horse is boarded)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Accepts Text Messages to this number

YesNo
Email
example@example.com
Horse's Name
Breed
SEX

StallionMareGelding
Age
Height
Weight
Time Owned
Current Veterinarian Name & Phone Number
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 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?
Please mark all that apply to your horse to help me get to know them and have a better idea of history.
Please check if your horse is sensitive to being

PregnantLaminitisGastric ulcersNavicularGirthed/Cinched upFrequent colicEye ProblemsGroomed over backOpen woundsEar ProblemsTouched near sheath/uddersSkin disorderHip ProblemsGrooming over ribs/barrelNewly healed woundLeg ProblemsTouchy around earsArea of sear tissueHeart ProblemsDifficulty bridlingInfectious disease last 6 monthsTeeth IssuesCancerDifficulty bending (Lor R)Nerve damageInability to collectAllergiesInability to pick up correct leadJoint pain/Arthritis/SwellingHistory of abuseDise/Vertebrae ProblemsHas/does set back when tiedUndiagnosed lumpRecurrent Lameness
If you marked yes to any of the above please explain
Release of Liability:
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.

HORSE OWNER/GUARDIAN HAS BEEN NOTIFIED THAT EQUINE MASSAGE THERAPY/COLD LASER THERAPY/COP MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY/ACUPRESSURE 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. HORSE OWNER/GUARDIAN HAS BEEN NOTIFIED THAT PAYMENT MUST BE MADE UPON ARRIVAL OF THE EQUINE MASSAGE THERAPIST. IF PAYMENT IS NOT MADE AT THIS TIME, THERE WILL BE NO SERVICE PROVIDED. THERE ARE ABSOLUTELY

HORSE OWNER/GUARDIAN HAS BEEN NOTIFIED THAT CEILAJ. REILY D.B.A. UNIVERSAL CONNECTIONS, LLC RESERVES THE RIGHT TO MAINTAIN A 24 HOUR CANCELLATION POLICY. APPOINTMENTS MUST BE CANCELLED WITHIN 24 HOURSOF THE SCHEDULED MEETING; OTHERWISE, CLIENTS WILL BE CHARGED $35 FEE FOR SERVICES. EXCEPTIONS CAN BE MADE TO THIS POLICY. • HORSE OWNER/GUARDIAN WILLFULLY AGREES TO SUBMIT HIS/HER CONSENT TO ALLOW CEILA J. REILY D.B.A. UNIVERSAL CONNECTIONS, LLC THE PERMISSION TO PERFORM EQUINE MASSAGE THERAPY/COLD LASER THERAPY/CORE MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY /ACUPRESSURE INTERVENTION ON HIS/HER HORSE TODAY AND ON ALL FUTURE DATES. • HORSE OWNER/GUARDIAN AGREES TO RELEASE CEILA J. REILY D.B.A. UNIVERSAL CONNECTIONS, LLC FROM ANY LOSS, DAMAGE, LIABILITY OR INJURY ARISING OUT OF, OR RESULTING FROM, PARTICIPATION IN EQUINE MASSAGE THERAPY/COLD LASER THERAPY/CORE MUSCLE STEM THERAPY/CRANIOSACRAL THERAPY/ACUPRESSURE, INCLUDING ANY NEGLIGENT ACTS. • HORSE OWNER/GUARDIAN AGREES TO INDEMNIFY, HOLD HARMLESS AND DEFEND CEILA J. REILY D.B.A. UNIVERSAL CONNECTIONS, 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.
Name

First NameLast Name
(SIGN NAME)

Clear
This is completely OPTIONAL:

I hereby grant CEILAJ. REILY D.B.A. UNIVERSAL CONNECTIONS, the right to take photographs and videos of me and my property (i.e. horse) in connection with the above identified subject. I authorize CEILAJ. REILY D.B.A. Universal Connections, 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. UNIVERSAL CONNECTIONS, 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.
Signature

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Date

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