Equine Hair Tissue Mineral Analysis Intake Form

Name

Address

City

Postal Code/Zip Code

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Name of Horse

Breed

Age

Weight

Gelding or Mare

Pregnant Yes/No

Date of Hair Sampling

Colour of Hair

What are the primary and current health concerns?

List past health concerns.

List any known allergies or sensitivities.

List the types of chemical or herbal dewormers that were use in the last 12 months and the months they were given.

List your horse's vaccine history and when they were administered.

List any other information that is relevant to your horse's health conditions including behaviour, herd dynamics, and emotions.

How long have you owned your horse?

Which activities/riding does your horse do?

What type of hay, grain and/or feed is your horse currently eating?

If your horse is on any commercial feed, please attach an ingredient list. **Note: a Guaranteed Analysis is NOT an ingredient list. Please list the exact ingredients e.g. alfalfa, oils, corn, wheat, beet pulp, soybeans, minerals etc.

Commercial Feed Ingredient List (if applicable)

Please attach a Hay Analysis of your horses current hay if you have one

List all medications and/or supplements including vitamins/mineral mixes

Attach an ingredient list or picture of the label for all combonation supplements.

Please do not provide the website link in lieu of an ingredient list.

A. Please be sure to include two pictures of your horse. The best pictures are taken outside in good light. Ensure that there is no blur. Take one complete body picture (no blanket) and one portrait picture showing your horse’s face.

B. If your horse has laminitis, hoof problems, or suspected hoof problems, you must also include three pictures of one barefoot front hoof (no shoes).

Set your horse’s hoof on a flat surface – concrete, wood, or dry ground. Do not take
pictures of your horse standing in grass, hay, snow, sawdust, bedding or other debris. Ensure that there is plenty of light – outdoor pictures are best.

1. One picture of the bottom sole. Make sure that the sole is cleaned out of manure, dirt, ice, snow, and other debris.

2. One picture of the side of the hoof taken from GROUND level. If you have a camera that is not a cell phone, you can set the camera right on the ground. Make sure that the picture is taken directly from the side at a 90-degree angle, not from a diagonal 45- degree angle.

3. One picture of the front of the hoof taken from GROUND level
Take hoof pictures within one week of the last trim.

Cutting the Hair Sample
Take a hair sample that weighs approximately 125 mg (about ½ Tablespoon) as close to the skin as possible from the base of the mane. Wash the testing area with plain water and then let dry.
• The hair should be no longer than 1-1/2 inches.
• Cut the extra length off and keep the 1-1/2-inch section which was closest to the skin.

Mailing the Hair Sample
Place the hair sample in a paper envelope. Do not use plastic or zip-lock baggies and donot tape the sample to a piece of paper or put it in aluminum foil. Plastic, glue andaluminum will contaminate the hair sample.

This consultation is intended to provide health information and Marijke van de Water, Marijke’s Intuitive Healing Services Ltd., and Riva’s Remedies Ltd. reminds clients that this information is not intended to be used as a diagnosis or to treat specific health problems or diseases for their animals. The information should not be considered as a substitute for qualified veterinary advice. In the holistic health care model, our aim is to support wellness of the whole body.
We also provide information on products, but it is the client’s responsibility to ensure that any products used are appropriate and that there are no contraindications for their specific situation.

Marijke van de water, Marijke’s Intuitive Healing Services Ltd. and Riva’s Remedies Ltd. and their owners, employees or affiliates will not be liable or responsible for any loss, damage or health problems caused directly or indirectly by the use or attempted use of any of the information or products. People should always seek the services of a qualified health care professional.

Signature

Date

Riva’s Remedies Ltd.
#4 – 1390 Pleasant Valley Road
Spallumcheen, B.C. V4Y 0W6
Phone: 250-546-0669
Fax: 250-546-0663

Email: reception@rivasremedies.com
www.rivasremedies.com
www.marijke.com

Hair Tissue Mineral Analysis

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Health Information

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Hair Sample

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