Initial Intake Form

Initial Intake Form

To be completed by all new clients.
If you are a new UK-based client, please obtain a vet referral 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

Street Address Line 2

CityState / Province

Postal / Zip Code
Animal Information
Animal's Name*
Referred Animal is*

HorseDogOther
Gender*

MaleFemale
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.
Registered Veterinarian*
Vet's or clinic's name
I give permission to the therapist to discuss condition and treatment with my vet.*

Yes.No.
Upload Relevant Evidence

Please, insert relevant documents (vet reports, RTG etc.).
Cancelof
Declaration
Owner's Signature*

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Should be Empty:

Client Information