Large Animal Intake Form | Earth Horse Healing

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.

"*" indicates required fields

Name of Owner*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Name of Large Animal*

Description

Species

Breed*

Color*

Height and approximate weight

Sex*

Female

Male

Male-Castrated

Age*

The Age Specified Is:*

Actual

Estimate

Aquisition

Year of Aquisition*

Where did you obtain the animal from?*

Please tell me about the animal's life, prior to your acquisition, if known:*

Lifestyle and Management

Daily Feed/Forage*

Daily Supplements*

Living Quarters*

Caged or stalled? How many hours a day inside or outdoors? On grass or dirt?

Medical History

Include anything historic and significant that has occurred while you have cared for this animal and prior to your acquisition, if known.

Any health issues in the past?*

Surgery, illness, malnutrition, etc.

Any past lameness, injuries or accidents?*

Abscess, tendon strain, arthritis, fall, injury, etc.

Current Condition

Any health issues this animal 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 animal is currently taking: dosage; start and end dates of meds; and why.

Any behavioral problems or vices?*

Is your animal comfortable being touched all over its body?*

Yes

If No, please explain:

Where on its body is it not comfortable being touched and what is his or her reaction?

Description

Aquisition

Lifestyle and Management

Medical History

Current Condition

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