Initial Intake Form

Initial Intake Form

To be completed by all new clients.
If you are a new UK-based client, please note a vet referral will be obtained from your registered vet in compliance with the Veterinary Surgeons Act, 1966.

Estimated completion time ~ 2 mins.
Client Information
Full Name
Email
Phone
Home Address

Street, City, Postcode

Street Address Line 2

CityState / Province

Postal / Zip Code
Stable/Address for Appointment

Yard name or address for appointment

Street Address Line 2

CityState / Province

Postal / Zip Code
Your availability.
Flexible; no Mondays; Thursday and Friday morning only; any day after 15:00 etc.
Animal Information
Animal's Name
Referred Animal is

Other
Gender
Year of Birth
e.g. 2018
Breed
e.g. Greyhound, Warmblood, Mix etc.
Reason for Booking
Diagnosed or suspected issues and current concerns.
Clinical History
All pre-existing medical conditions, diagnoses and interventions.
Medication
Current medication including meds ceased in the last 2 weeks.
Activity
Dogs: Length and frequency of walks, off/on lead, intensity (e.g.: 2x30 minutes slow-walk on short lead). Horse: Weekly regime, turnout, frequency and intensity of training, ambition (e.g. 6h a day on paddock, 2x hacking, 2x flat work, 1x jumping to 120cm, 1x ground work, 1 day off).
Registered Veterinarian
Vet's or clinic's name
I give permission to the therapist to discuss condition and treatment with my vet.
Upload Relevant Evidence

Please, insert relevant documents (vet reports, RTG etc.).
Cancelof
Declaration
Owner's Signature
Should be Empty:

Initial Intake Form

Client Information

Animal Information

Declaration