You can always press Enter⏎ to continue
Welcome!

Welcome!

Thank you for choosing Anna Gezon Equine Massage Therapy LLC.  This intake form helps me learn about your horse's medical history, current concerns, and goals so I can provide the safest and most personalized treatment possible.   Please allow approximately 5–10 minutes to complete this form.    A separate form is required for each horse receiving services.
  • 1
    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    -
    Pick a Date
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Press
    Enter
  • 11
    Press
    Enter
  • 12
    Please Select
    • Please Select
    • Hunter Jumpers
    • Equitation
    • English
    • Pleasure
    • Trail
    • Dressage
    • Jumping
    • Western
    • Eventing
    • Racing
    • Reining
    • Working Cattle
    • Therapy
    • Breeding
    • Other
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Press
    Enter
  • 18
    Press
    Enter
  • 19
    Press
    Enter
  • 20
    Such as joint injections, chiropractic care, acupuncture, shockwave therapy, PRP/IRAP, stem cell therapy, vaccination in the last 48 hours or other veterinary procedures.
    Press
    Enter
  • 21
    Press
    Enter
  • 22
    Press
    Enter
  • 23
    -
    Pick a Date
    Press
    Enter
  • 24
    Press
    Enter
  • 25
    Press
    Enter
  • 26
    Press
    Enter
  • 27
    Press
    Enter
  • 28
    Press
    Enter
  • 29
    Press
    Enter
  • 30
    Press
    Enter
  • 31
    Press
    Enter
  • 32
    Press
    Enter
  • 33
    Press
    Enter
  • 34
    Changes may be noticed under saddle, on the ground, during grooming or handling, in the stall or pasture, or in your horse’s overall attitude and performance.
    Press
    Enter
  • 35
    Press
    Enter
  • 36
    Press
    Enter
  • 37
    Press
    Enter
  • 38

    CONSENT AND WAIVER – EQUINE BODYWORK SERVICES

    I understand that the services provided by Anna Gezon Equine Massage Therapy LLC, including but not limited to equine massage therapy, Pulsed Electromagnetic Field (PEMF) therapy, intelligent negative pressure cupping, scraping, and red light therapy, are complementary wellness modalities and are not a substitute for veterinary care.

    I acknowledge that:

    • These services are non-diagnostic and non-prescriptive in nature.

    • Anna Gezon and any associates or independent contractors are not veterinarians and do not diagnose illness or injury or prescribe treatment or medication.

    • It is my responsibility to consult with my veterinarian regarding any health concerns, diagnoses, injuries, or ongoing medical treatments involving my horse.

    • I have accurately disclosed all known medical history, medications, injuries, procedures, behavioral concerns, and conditions that could affect my horse’s ability to safely receive services.

    • I will notify Anna Gezon of any change in my horse’s health, condition, pregnancy status, medication, veterinary treatment, or behavior before future sessions.

    • I understand that services may be modified, postponed, or discontinued if Anna believes treatment may be unsafe or veterinary evaluation may be appropriate.

    • I understand that no specific result or outcome is guaranteed.

    • I understand that temporary responses such as fatigue, soreness, increased thirst, changes in movement, or sensitivity may occasionally occur following a session.

    I voluntarily consent to the selected services being provided to my horse.

    By signing this release, I authorize Anna Gezon Equine Massage Therapy LLC to provide these services to my horse and release Anna Gezon, CEMT, and any representatives, associates, or independent contractors of Anna Gezon Equine Massage Therapy LLC from liability arising from the ordinary and appropriate provision of these services, to the extent permitted by law.

    Press
    Enter
  • 39
    Press
    Enter
  • 40
    Press
    Enter
  • 41
    Press
    Enter
  • 42
    Please Select
    • Please Select
    • Owner
    • Lessee
    • Trainer
    • Caregiver
    • Other
    Press
    Enter
  • 43
    Press
    Enter
  • 44
    -
    Pick a Date
    Press
    Enter
  • 45
    Press
    Enter
  • 46
    If yes, personal information will remain private and only your horse’s first name and image may be shared.
    Press
    Enter
  • 47
    Press
    Enter
  • Should be Empty:
Question Label
1 of 47See AllGo Back
close