Follow Up Intake Form For Natural Horse Health Assessment

Follow Up Intake Form

For Natural Horse Health Assessment
Date*

MonthDayYear
Date
Contact Information*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

HORSE PROFILE

Breed / Sex / Age / Health Concerns

Progress Report

Health Conditions / Stresses / Trauma
List the top 3 primary concerns addressed in the last program and indicate the change observed and to what degree.*
List all other observed changes to health and behaviour (physical / mental / emotional).
Please include current pictures of your horse, one full side body view and one head view taken from the front which included a clear view of the muzzle and ears. If you submitted hoof pictures for your initial consult and have had a trim since please include updated pictures, one of the sole, one from the side taken at ground level and one from the front taken at ground level. Please limit picture file size to 300kb each.

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DIET AND SUPPLEMENTS

Forage / Vitamins / Minerals / Ingredients
Diet - List all current feed items your horse is eating. (you can add more by clicking the button below)*
Nutrients - List the current supplements/vitamins/minerals for your horse since last assessment. (you can add more by clicking the button below)
Natural Remedies - Please list all other remedies being administered since the last assessment.
Have there been any changes to your horses original health profile since the last assessment?
Please upload any recent hay analysis, fecal count reports or hoof X-rays if applicable or any other items which are relevant for the follow up review.

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DISCLAIMER

This consultation is intended to provide health information and Elisha Edwards Inc. 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 advise. 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.

Elisha Edwards, Elisha Edwards Inc. and their owners, employees, or affiliates will not be held 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. The client should always seek the services of a qualified health care professional.

I understand that by signing and submitting this form I have agreed to waive and relinquishe any and all claims against Elisha Edwards, Elisha Edwards Inc., their family, extended family, heirs, owners, employees, contractors, affiliates, administrators, executors, or assignees.
Date of Signature:*
Printed Name of Signatory:*
Once you have signed the form with your finger or mouse please be sure to click continue, and authorize by accepting the terms on the next page. This will take you to the scheduling page where you can book your appointment with Elisha.
Signature Of Client*

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Elisha Edwards Inc., 34131 Township Rd 262, Cochrane, AB T4C 14P

Email: consults@elishaedwards.com, Website: https://elishaedwards.com
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Follow Up Intake Form

HORSE PROFILE

Progress Report

DIET AND SUPPLEMENTS

DISCLAIMER