Medical History & Consent to Treat

History & Consent to Treat

Please tell us why we are seeing the below named horse & agree for In Stride Equine Wellness LLC to treat them. One form per horse.
Date of Appointment:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Full Name

First NameLast Name
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Your Horse's Name
Reason for Wellness Visit:
Primary reason/concern for your visit today
Please describe any issues you have been seeing and share any additional history
Please list the wellness therapies you would like done
Please check all locations that apply to today's visit:

Other
Behavior:
For the safety of everyone please check all that apply:

Other
Consent to Treat

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent.
I hereby consent and authorize In Stride Equine Wellness LLC, to perform wellness therapies that could include but are not limited to: cryotherapy, red light therapy, 3b laser therapy, massage gun therapy.

The nature of these wellness therapies have been explained to me, and I understand what will be done.
Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

History & Consent to Treat