Equine Bodywork Intake Form 🐴✨
Please provide details about your horse and massage needs to help us prepare for the session.
Today’s Date
-
Month
-
Day
Year
Date
Owner's Full Name
*
First Name
Last Name
Mailing/Billing Address
Street Address
Street Address Line 2
City
State
Zip Code
Barn Address - Where your horse lives
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Owner's Email Address
example@example.com
Preferred Contact Method
Text me at this number
Email Only
Call Only
No Preference
Horse's Name
*
Horse's Breed
Horse's Age
*
Reason for Massage / Areas of Concern
*
Does your horse have any current injuries or medical conditions?
*
No
Yes (please describe below)
If yes, please describe any current injuries or medical conditions.
Past injury/surgical history
Please list current medications/supplements
Has your horse received equine bodywork before?
Yes
No
Veterinarian's Name (optional)
Additional Comments or Special Instructions
Scope of Practice
I can not/will not:
diagnose, prescribe or perform veterinary procedures
guarantee outcomes
override veterinary advice
work on horses with issues contraindicated for massage/MFR/PEMF
recommend skipping veterinary care
I can/will:
respect your time
apply approved techniques to support relaxation, comfort & performance
refer & collaborate with equine professionals when signs are presented out of my scope of practice
maintain confidential records
prioritize safety at all times
Signature
Submit Intake Form
Submit Intake Form
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