Client Information

Client Information
First Name*
Last Name*
Email
example@example.com
Street Address
Phone Number
Horses Name
Breed
Horse’s Age
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In case of emergency, we will contact the person below:
Veterinarian or Emergency Contact Name
Emergency Contact Details
Phone Number
Relationship
Health Data
Mare, Gelding or Stallion
A-Pregnant or nursing? B-Last Sheath Cleaning? C-Teeth Floated? D-Farrier Visit?
Specific nutrition requirements. Any specialty feeds of supplements?

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Current medical conditions like EPM, PPID, Cushings, Laminitis, PSSM
If yes, please specify on the field above.
Date of last Vaccines

MonthDayYear
Date
Is your horse currently taking any medications?
If yes, please specify on the field above.
Does the horse have any current known injuries / recently hospitalizations?
If yes, please specify on the field above.

Location of painful areas or areas of concern

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Does the horse have any known behavioral issues that the student should be aware of i.e. biting, kicking, head rubbing, pawing, cribbing, or wind sucking
Any questions/Concerns
Consent and Waive
I, undersigned, agree with the following statements:

I understand that I should consult my Veterinarian before any procedure.
I understand that Langley Equine Studies strongly encourages me to communicate with my veterinarian

I authorize this massage practitioner to perform the treatment or necessary procedure for my horse.I acknowledge that I have consulted a veterinarian before undergoing this massage treatment.I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my veterinarian prior to treatment.I acknowledge that all information I provided in this form is true and accurate.
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Photo Release (Optional)
I hereby grant permission to Jaime Smith- Stay Golden Equine Massage to use photographs and/or video of

my horse in publications , news releases, online, and in other communications related to Equine
Bodywork for Educational and/or Advertising materials
Date Signed

MonthDayYear
Date
Month/Day/Year
Tags

To-doIn ProgressDone
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Massage Therapy Consent to Treat
Should be Empty:

Client Information

Health Data

Consent and Waive

Photo Release (Optional)