Therapeutic Horse Session Patient Details

Therapeutic Horse Session Patient Details
Name of adult/ child wanting to participate*

First NameLast Name
Name of adult/ child wanting to participate (if more than one)

First NameLast Name
Adults or Parent's / guardian's phone number*
Parent's / guardian's full name (if session is for a child)
Adults or Parent's / guardian's email address*
example@example.com
Date of birth or the participant *

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal Code
Do you/ they have any health conditions that are currently affecting your/ their daily life? i.e. mental health, learning disability, physical disability*
Is there any other information that you think would be beneficial to know to ensure you feel safe and happy during your/ their time with us?*
Do you/ they have any experience with horses? If so please give a summary*
Do you/ they have any worries or anxieties about being with horses?*
Would you like someone call you to discuss these sessions?*
Would you like to book one or multiple sessions?*
Name of the person completing the form*
Relationship to the participant (if your are not the participant)
Medical records will be held securely via our GDPR compliant clinical system. Our privacy policy can be found on our website. Please confirm that you have read this policy. By accepting an appointment, you confirm that you agree with our terms.

IMPORTANT I confirm I have read the Privacy Notice and agree to the Terms and Conditions on the Makewell Website.

Adults or Parent/Guardian signature - Digital signature on this form. This serves as confirmation of the signer's acknowledgment and agreement to the terms, in accordance with applicable electronic signature regulations.
Signature*

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