Horse/Equine Intake Form Please fill out and submit this form at least 48 hours prior to your initial appointment. Required fields are marked with a red asterisk. The information you provide is held as private and will not be shared without your expressed permission. Name of Owner* First Last Address/Location of Horse* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your Cell Number*For calls and text messages.DescriptionName of Horse* Breed* Color* Size In HandsSex* Mare Gelding Stallion Filly Colt Age* The Age Specified Is:* Actual Estimate AquisitionYear of Aquisition* Where did you obtain the horse from?*Please tell me about the horse's prior use, if known:*Lifestyle and ManagementDaily Feed and Hay*Daily Supplements and Herbs*Turn-out Schedule* How many hours a day? On grass field or dirt paddock?Do you utilize fecal testing?* Yes No How frequently do you worm?* As Needed Routinely Daily Vaccinations: History and Present Routine*Please list vaccinations and include frequency of shots. Also, please explain if and how the routine and frequency has changed over the years.Hoofcare* Barefoot Shod Special Shoeing If barefoot: since when?If your horse requires special shoes, please explain: for what condition, the type of shoe(s) and when the corrective shoeing began.Farrier or Natural Hoof Trimmer's Name For reference only. I will not contact the individual unless you ask me to do so.Medical HistoryInclude anything historic and significant that has occurred while you have cared for this horse and prior to your aquisition, if known.Any health issues in the past?*Colic episodes, surgeries, illness, malnutrition, etc.Any past lameness, injuries or accidents?*Abscess, tendon strain, arthritis, fall, flip, head injury, etc.Current ConditionAny health issues this horse has presently.Current Veterinary Diagnosis*Name of Veterinarian and Practice For reference only. I will not contact your veterinarian unless you specifically ask me to.Current Medications*Please list any medications your horse is currently taking: dosage; start and end dates of meds; and why. Include Phenylbutazone (Bute.)Any behavioral problems or vices?*Is your horse comfortable being touched all over its body?* Yes No If No, please explain:Where on its body is it not comfortable being touched and what is his or her reaction?Your Relationship With Your HorseThis section is optional.What is your current exersize program; for which discipline are you training?What do you and your horse enjoy doing together?Healing Session FocusPlease take the neccessary time to consider the following questions.What needs do you and your horse have that you would like to be addressed during the healing session?*Where do you seek growth or improvement in your relationship with your horse?*Examples: Deepening the bond between us, more mutual understanding or clearer communication.