Consent & Initial Intake Form

Consent & Initial Intake Form

For new clients and bookings
Owner Information
Name

First NameLast Name
Email
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment Availability
Please note that current availability for New West Equine Services is currently Mondays and Wednesdays 8am-1:30pm, and Tuesdays 8am-4pm
Client Information
Demographic Information
Name
Breed
Sex
Colour
Height (HH)
Weight (lbs)
Age
When did you get this horse?
Horse's Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Past and Current Discaplines
Quirks (ex. girthy, bites, kicks, anxious)
Medical Maintenance and History
Current Vet
Last Vet Check and Why
Last Vaccinations
Last Dewormer
Current Farrier
Last Farrier Visit
Current Medications
Current Supplements
Current Injuries/Concerns
Past Injuries/Concerns
Training and Exercise
Current Exercise Regiment
Training and Performance Goals
Acknowledgment of Consent
I understand that massage or other modalities are never a replacement for proper veterinary care. I understand that the New West Equine Services 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 appropriate for the horse.

I understand that information and findings from each session will be recorded and kept by New West Equine Services for up to 7 years, and can be requested at any time. Session reports will automatically be provided upon completion of individual sessions. Personal information will never be shared with a non-listed third party.
Name: Relation: Contact:
Name: Relation: Contact:
Name: Relation: Contact:
I consent to photo/video of my horse to be used for promotional purposes:*

YESNO
Conset*

I understand and accept the terms of New West Equine Services
Should be Empty:

Consent & Initial Intake Form

Owner Information

Client Information

Demographic Information

Medical Maintenance and History

Training and Exercise

Acknowledgment of Consent