Intake Form

Liability Waiver
Date

DayMonth Year
Date
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.
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Printed Name*

First Name Last Name

Client Information
Email*
example@example.com
Phone Number*
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Preferred Method of Contact

EmailPhone CallTextNo Preference
How did you find out about Vitality Equine?
Name of Referral, if applicable.
Would you like to receive news and promotions from Vitality Equine?

Yes, pleaseNo, thank you

Equine Athlete Information
Name of Equine Athlete
Name of Equine Facility/Barn/Acreage
Address of Equine Facility/Barn/Acreage

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Discipline
How long have you owned this horse?
Breed
Age
Colour
Sex

MareGeldingStallion
Team Members
Attending Veterinarian
Farrier
Trainer (if any)
Chiropractor
Additional Members
Equine History & Health Information
Describe your training/conditioning program, please include how many days a week you ride/work with your athlete.
What are your goals and intentions with your horse?
When is your next show? (If applicable)
Are there any personality traits or nuances Vitality Equine should be aware of before the session (i.e. cribbing, nipping, anxious when alone..etc)
When was the last time your horse was seen by a veterinarian, and why?
Is your horse currently on any medications, nutraceuticals or supplements? If yes, please list them below.
When was your horse last vaccinated?
When was your horse last dewormed?
When were your horse's teeth last addressed?
When was the last time your saddle was fitted?
What is your horse's feeding regime and schedule?
What is your horse's current housing and turnout schedule?
What is your intention for scheduling this massage? Well-being, or do you have a specific concern?

Payment Terms
I understand that all payments are due and payable on date of service. I understand that Vitality Equine accepts e-transfer (vitalityequine@gmail.com), cash, cheque (made payable to Vitality Equine) and credit cards (Visa and MasterCard). I recognize that if I would like to pay my invoice with a credit card that an additional 3% service charge will be incurred. I agree to leave my credit card on file, in case of late payment.

Late Payment. If payment is not received within 30 days of the invoice date, I understand that my credit card on file will be charged for the total amount and the additional 3% service charge.
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Credit Card on File Information

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Expiration Date*
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CVV*
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