Horse or Equine Intake Form

Equine Intake

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
Email*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Location of Equine(s)*
- At home
- A facility
Address of Equine Facility
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Skype name if you live outside of the USA
Appointment Scheduling*
- M-Fri: 10-12:00 am ET
- M-Fri: 2-4:00 pm ET
- M-Fri: 6-8:00 pm ET
- Weekends: for On-Site visits only
Please choose all the times you are available in Eastern Time, thank you.
Description
Name of Horse*
Breed*
Color*
Size

In Hands
Sex*
- Mare
- Gelding
- Stallion
- Filly
- Colt
Age*
The Age Specified Is:*
- Actual
- Estimate
Aquisition
Year of Aquisition*
Where did you obtain the horse from?*
Please tell me about the horse's prior history and use, if known:*
Lifestyle and Management
Daily Feed and Hay*
Daily Supplements and Herbs*
Please provide brand names.
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
Vaccination History*
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 History
Include anything historic and significant that has occurred while you have cared for this horse and prior to your aquisition, if known.
Any past health issues: illness, lameness, injuries or accidents?*
Lyme, EPM, colic episodes, abscess, tendon strain, arthritis, fall, flip, head injury, surgeries, malnutrition, etc.
Current Condition
Any 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 Horse
This 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 Focus
Please 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.
How did you first hear about Earth Horse Healing?*
Would you like to be added to my email list?*
- Yes, please.
- I'm already on your list
- No, thanks.
For occasional announcements about events and classes.

Equine Intake

Description

Aquisition

Lifestyle and Management

Medical History

Current Condition

Your Relationship With Your Horse

Healing Session Focus

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