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.

"*" indicates required fields

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 or Teams phone number if you live outside of the USA

If you're located outside the USA, I'll initiate the call via Microsoft Teams or Skype for a desktop meeting.

Appointment Scheduling*

M-Fri: 10- noon ET

M-Fri: 2-4:00 pm ET

M-Fri: 6-8:00 pm ET

Weekends: 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*

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

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

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.