[Imported Form] Equine Client Card

Name of owner*

First NameLast Name

Phone of owner*

Email*

Address of owner

Street Address

Street Address Line 2

CityCounty

PostcodeCountry

Address of stables/yard (if different from address of owner)

Street Address

Street Address Line 2

CityCounty

Post CodeCountry

Name of horse*

Age*

Breed

Height

Sex*

Colour

How long owned

Address of Veterinary Practice*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry

Name of Vet

Phone of vet*

Workload of horse*

Activities of horse*

Saddle last checked?*

DayMonthYear

Last saw dentist?*

DayMonthYear

Please provide a history of significant illnesses and injuries, including ongoing medications.*

Reason for visit*

Merishia Massage is a soft tissue approach, using a combination of Swedish massage and Sports massage techiques along with mobilisations to help release areas of tension, aid and improve range of movement, and with the aim of enhancing overall emotional and physical wellbeing.

I understand that a Merishia Massage session does not replace veterinary advice but works in conjunction with it.

Should my animal become ill or injured any time between gaining vet permission and the session, I will inform my vet and Shelley Marie Streeter t/a SMS Animal Massage.

I consent to the above information being used and stored by Shelley Marie Streeter in accordance with the Data Protection Act 2018*

I do consentI do not consent

My vet is in agreement for my horse to receive massage therapy with Shelley Marie Streeter*

YesNo

Date

MonthDayYear