Equine Intake, Consent, and Liability Waiver

Equine Intake, Consent, and Liability Waiver

Standard online intake form for localized cryotherapy services at Callie’s Healing Hands. Please complete the required fields and review the consent and waiver information.
Horse Information
Horse Name
Horse Age
Stable
Intake Date

MonthDayYear
Date
Owner and Contact Information
Owner Name
Owner Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Owner Phone
Please enter a valid phone number.Format: (000) 000-0000.
Veterinarian Name
Veterinarian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Farrier Name
Farrier Phone
Please enter a valid phone number.Format: (000) 000-0000.
Health History and Condition
Conditioning Level

Other
Major Complaint (What, Where, When, How?)
Recent skin treatments or nerve blocks?
Open wounds or lesions?
Affected area clean and dry?
Photo Consent and Authorization
Photo Consent Level
Signer Role

Other
Signature and Agreement
Signature
Signature Date

MonthDayYear
Date
Should be Empty: