Veterinary Consent Form for Physiotherapy Treatment

New Client Information Form - Equine Clients

Please can all new equine clients complete this form prior to their appointment
Client Name*

First NameLast Name
Phone Number*
Home Address*

Street Address

Street Address Line 2

City/TownCounty

Postcode
University Address (complete if you are a university or college student)

Street Address

Street Address Line 2

City/TownCounty

Postcode
Yard Address (where horse is kept)*

Street Address

Street Address Line 2

City/Town County

Postcode
Email*
example@example.com
Normal Vet Practice Details (Address, Contact Number)*
** If you are a Hartpury Student please also include the details of the vets you are registered with at home
Referral Vet Practice Details (Address, Contact Number)
Horse Name*
Age/DOB*
Breed*
Sex*

MareGeldingStallion
Are vaccinations up to date?*

YesNoOther
Reason For Referral*
Pre-Existing Conditions/Injuries*
Current Medication/s*
Is your horse seeing any other professionals?*

OsteopathChiropractorMassage TherapistAccupunctureHydrotherapyNone
Declaration of Health: To the best of my knowledge, my horse has no current medical conditions, injuries or lameness*

I agree, there are no pre-existing medical conditions, injuries or lamenessI disagree, my horse has past/previous medical conditions, injuries or lameness
Terms and Conditions (Link: https://tinyurl.com/ycywvjsp)*

Yes, I agreeNo, I disagree
Use of Videography and Social Media (outlined in T&Cs)*

I agree to both social media and treatment monitoring purposesI only agree to social mediaI only agree to treatment monitoring purposesI disagree to both social media and treatment monitoring purposes
Date*
Signature*

Clear
Should be Empty:

New Client Information Form - Equine Clients