New Client Form & Release

Owner Name*

First NameLast Name

Owner Phone Number*

Please enter a valid phone number.

Owner Email*

example@example.com

Horse's Farm & Location

Barn Name

Street Address

CityState

Horse's Name, Age & Gender

2nd Horse's Name, Age & Gender

3rd Horse's Name, Age & Gender

List Additional Horses Here. Please note, if any horses listed have acute or chronic medical issues, please list those alongside their names.

Please let us know why you are seeking treatment for your horse(s)?

Has your horse(s) received Magnawave treatment in the past?

YesNoOther

Are you interested in Light Therapy as well?

YesNoOther

What medications is your horse(s) currently taking? *

Please be sure to indicate if your horse is taking any immunosuppressent drugs. If no drugs, just notate none. If listing multiple horses please indicate name next to medications.

Is your horse(s) in regular work?

What is your horse's discipline?

Is your horse(s) pregnant?

YesNoSupporting fertility

Has your horse(s) sustained a recent injury? If so, please explain. *

Please identify which horse you are referring to when describing injuries.

Is there any medical history that would be important to note in order to optimize your horse's treatment?

Please include past surgeries, colic, etc. Please be sure to identify which horse you are referring to if multiple horses are listed.

Has your horse(s) had EPM?*

YesNo

If yes, date of EPM. *

Veterinarian's Name*

First NameLast Name

Veterinarian's Phone Number*

Please enter a valid phone number.

Waiver & Release

PEMF creates more cell permeability, thus medications and liniments may be absorbed at a greater rate. Liniments and fly sprays should be avoided before treatment.

I hereby state that I am at least 18 years of age and have read, understand and agree to this Release Statement, that it is an informed release and that I am legally bound by it. I understand the information below is intended for my safety and that of my horse(s).

No one has made any representations or claims to me of any treatment or cure of any disease or condition; or any promise of any specific or general results of any kind.

I release from all general, medical and any other liability or claims of any kind; and, I indemnify and hold harmless the MagnaWave magnetic pulse generator, the manufacturer, distributor, dealer and any of their employees or agents from any claim arising from or related to my use of the magnetic pulse generator.

I hereby release and forever hold harmless Royal Equine Wellness, Inc., it's owner Tobi Kundid, as well as any associates, affiliates, staff contrators, agents and employees. I expressly agree to release and discharge any and all associates of Royal Equine Wellness and I release any right to bring legal action against the aforementioned corporation or its affiliates.

In the event that any damage to equipment or facilities occurs as a result of my pet's actions during treatment, Royal Equine Wellness and its affiliates shall not be held liable for any loss, damage costs or liability.

In signing this release, I acknowledge that I have read the Session Release, understand it, and agree to this waiver of liability.

Signature*

Date*

Date

Optional: Trainer Name (if authorizing for owner)

First NameLast Name

Trainer Signature

Date