Large Animal Intake Form Large Animal 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* Street Address 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 Name of Large Animal*DescriptionSpeciesBreed*Color*Height and approximate weightSex*FemaleMaleMale-CastratedAge*The Age Specified Is:*ActualEstimateAquisitionYear 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 ManagementDaily Feed/Forage*Daily Supplements and Herbs*Living Quarters*Caged or stalled? How many hours a day inside or outdoors? On grass or dirt outdoors? Do you utilize fecal testing?*YesNoHow frequently do you worm?As NeededRoutinelyDailyVaccinations: 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.Medical HistoryInclude 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 ConditionAny health issues this animal has presently.Current Veterinary Diagnosis*Name of Veterinarian and PracticeFor 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?*YesNoIf No, please explain:Where on its body is it not comfortable being touched and what is his or her reaction?Your Relationship With Your AnimalThis section is optional, you can skip to the next if you choose.What is your animal's current exersize program or training?What do you and your animal enjoy doing together?Healing Session FocusPlease take the neccessary time to consider the following questions.What needs do you and your animal have that you would like to be addressed during the healing session?*Where do you seek growth or improvement in your relationship with your animal?*Examples: Deepening the bond between us, more mutual understanding or clearer communication.