Equine Intake Form
Please take the time to fill out these prompts to the best of your knowledge
Horse Owner's Name
First Name
Last Name
Email
example@example.com
Date on Form
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you prefer contact via email or text/call?
Horse's Name(s)
Barn Name
Registered Name(if not applicable type N/A)
Horse's Breed
Horse's Age
Horse's Discipline
Horse's expected workload (days per week)
Do you have any competitions coming up?
Does the horse have any current or previous injuries?
Does this horse suffer from any skin conditions? ie: fungus(ringworm), rain scald, sores, sarcoids, mange, etc?)
Does Top Form Equine have permission to use fly spray? (If you like a specific one please provide it.)
Does this horse have any stable vices?
Please list any problems you've been noticing with your horse: (ie, reluctance to move forward, tension, behavioral changes, back soreness, hoof issues, metabolic disorders, EPM, lymes disease, etc)
Is this horse up to date on health examinations? (within the last 6 months)
Yes
No
How did you hear about Top Form Equine?
Does Top Form Equine have permission to use photos/videos of your horse on social media, business page, or as educational content?
*case by case basis, TFE will seek approval of any post prior to publicizing*
Do you agree the appointment shall be made no sooner than 48 hours prior to an extensive travel day?
*horses need plenty of time to replenish electrolytes after a massage, many horses do not properly rehydrate when traveling*
Do you agree to contact your veterinarian to ensure massage is an appropriate modality for your horse? Must be done prior to appointment. *requirement by Utah Law
Please sign, you agree to obtain your vet's referral for horse referred to in this form:
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