Equine PEMF Intake Questionnaire
PEMF and Red Light/Near Infrared Light Therapy
Owner Information
Owner Information
Full Name
*
First Name
Last Name
Are you 18 or older?
*
Please Select
Yes
No
I am Parent/Guardian of Horse Owner
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
How would you like to be contacted?
*
Text
Phone Call
Email
Address
Street Address
Street Address Line 2
City
Province
Postal Code
Additional Ownership Name & Contact Details
Farm Information
Farm Information
Farm Name
Farm Address
*
Horse Information
Horse Information
Horse's Name
*
Age/Date of Birth
Sex
*
Please Select
Gelding
Mare
Mare in foal
Stallion
Breed
I am interested in the following therapies for my horse:
PEMF Therapy
Red Light
Bodywork (Tension Release)
Veterinarian
Date of Last Dental
Date of Last Trim
What's your horse's trim/farrier schedule?
ex: every 4 weeks, 6 weeks, etc
Medications (or none)
*
Any surgeries, screws, or plates? Please describe (or none)
*
Include date/year of surgery.
Any health conditions? Please describe (or none)
*
Include how long condition has existed, and/or date of diagnosis.
If yes, what treatment/management is being done?
Any recent injuries? Please describe
Reason for Nutrition PEMF and/or Red Light/Near Infrared Light Therapy
*
Is there a special event for which you want consultation or therapy before or after? If so, briefly detail and include date. (I can't make promises at this stage, but I do my best to accommodate.)
Exercise/Activity Level and Frequency
Does your horse get added salt?
Please Select
Yes, in feed daily
Yes, in feed daily with access to a block
Yes, but only access to a block
No
Your availability - Please let me know your preference for days/dates/time of day and I'll do my best to accommodate. (Please note practitioner availability is weekends with limited evenings.)
Legal
Legal
Please read carefully:
I understand that PEMF/Light therapy is not a replacement for medical care and no diagnoses will be made.
*
Yes
No
I have reviewed the Release from Liability Form (below) and accept and can adhere to all terms. (A physical copy will be provided at your appointment to sign.)
*
Yes
No
PEMF Therapy Release from Liability
I hereby release and discharge MearaPulse Therapies, its practitioners, agents, and representatives, from any and all claims, liabilities, demands, actions, causes of action, costs, and expenses, whether at law or in equity, arising out of or in connection with my participation in PEMF and/or light therapy sessions.
*
Yes
No
I understand that fees owing must be paid within 30 days of services being performed or I will be subject to an interest of 10% added and compounded monthly.
*
Yes
No
(Optional) I consent to letting MearaPulse Therapies use photos of my horse on their social media and/or website, or for training purposes.
*
Yes
No
Legal Name (or Name of Parent/Legal Guardian)
*
First Name
Last Name
Signature
*
Submit
Submit
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