PPES New Client Intake Form

Client Information
Owner/Lessee*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

If applicable: Navigation Notes (will GPS take me to correct location? If needed: landmarks, barn color, which drive, gate code, etc)

CityState / Province

Postal / Zip Code
Is horse's location same as mailing address?*

YesNo
Horse Location

Street Address

Navigation Notes (will GPS take me to location? If needed: landmarks, barn color, which drive, gate code, etc)

CityState / Province

Postal / Zip Code
Vet
Farrier
By signing this form, I understand that that the services being performed by the Equine Bodywork Practitioner are not an alternative to proper veterinary care. I understand that the practitioner will not diagnose, prescribe, or practice veterinary medicine. I understand that it is my responsibility to consult with my veterinarian regarding complimentary care for my horse. I hearby release, waive, and forever discharge the Equine Bodywork Practitioner from all claims, demands, actions, and causes of action of any kind of nature.
LIABILITY WAIVER/DISCLAIMER AGREEMENT*

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Horse Information
Horse Name*
Breed
StallionGeldingMarePregnant Broodmare
Color*
HeightWeight
Age
Discipline/Use
Does this horse have a pattern of aggression (frequent biting, kicking, charging, etc) towards people? This doesn't affect whether I will work with your horse or not, this is good information for everyone's safety.*

YesNo
If yes, please explain
Current & Past Medical History
Major Complaint
Any other questions, concerns, etc.

Add Another Horse
Horse Name
Breed
StallionGeldingMarePregnant Broodmare
Color
HeightWeight
Age
Discipline/Use
Does this horse have a pattern of aggression (frequent biting, kicking, charging, etc) towards people? This doesn't affect whether I will work with your horse or not, this is good information for everyone's safety.

YesNo
If yes, please explain
Current & Past Medical History
Major Complaint
Any other questions, concerns, etc.

Add Another Horse
Horse Name
Breed
StallionGeldingMarePregnant Broodmare
Color
HeightWeight
Age
Discipline/Use
Does this horse have a pattern of aggression (frequent biting, kicking, charging, etc) towards people? This doesn't affect whether I will work with your horse or not, this is good information for everyone's safety.

YesNo
If yes, please explain
Current & Past Medical History
Major Complaint
Any other questions, concerns, etc.

Add Another Horse
Horse Name
Breed
StallionGeldingMarePregnant Broodmare
Color
HeightWeight
Age
Discipline/Use
Does this horse have a pattern of aggression (frequent biting, kicking, charging, etc) towards people? This doesn't affect whether I will work with your horse or not, this is good information for everyone's safety.

YesNo
If yes, please explain
Current & Past Medical History
Major Complaint
Any other questions, concerns, etc.

Invoicing and Payment Policies
Invoicing and Payment Policies

Invoices will be sent via email/text to clients post appointment and are due upon receipt(unless exceeding a certain amount for multiple horses). Payment is also accepted at time of service. I accept cash, check, Venmo, Zelle, and EChecks (ACH Bank Transfer) through QuickBooks. If clients wish to pay by credit card, clients will be responsible for the credit card fees and need to let me know before the invoice is sent. Invoices that remain unpaid beyond 30 days will incur late fees.
I have read the above information and understand the information above*

Yes

Please alert me to any changes to your horse's health pre-appointment
Please alert me to any changes to your horse's health as soon as possible pre-appointment

This includes sudden severe lameness, fever/signs of sickness, suspicion/confirmation of neurological disorders such as EPM, starting new medications, any/all recent injections, recent vet work or diagnostics that could affect our appointment, etc. I cannot work on horses within a week of receiving vaccinations. I cannot work on horses who have been injected with Adequan or Legend within 48-72 hrs prior to our appointment. It is best to reschedule if the horse has received sedation within 24 hrs of appointment. I cannot work on horses within a certain time frame of joint injections. Cancelation within the same day of the scheduled appointment will result in a $25 cancelation fee and cancelation that is necessary upon arrival at appointment due to failure to communicate any of the changes listed above will result in a $45 cancelation fee. I am always happy to work with owners and understand that life/horses are good at causing sudden changes in our schedules! There are exceptions to these cancelation policies due to emergencies and special circumstances.
I have read and understand the information above*

Yes

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