Small Animal Intake Form Animal 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 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 Email Phone number you'll call me from*Skype name, if calling from outside 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 Please choose all times you are available in Eastern Time, thank you.DescriptionName of Animal* Species* Common name is fine.Breed* Color Sex* Female Spayed Female Male Neutered Male Age* The Age Specified Is:* Actual Estimate AcquisitionYear of Acquisition* Where did you obtain the animal from?*Please tell me about the animal's prior situation, if known:*Lifestyle and ManagementDaily Diet: Please be specific: wet or dry, brand name with flavors.*Daily Supplements and Treats: Please give brand names.*Vaccinations: History and Present Routine*Please describe your animal's lifestyle, exercise program and access to the outdoors.*Medical HistoryInclude anything significant that has occurred while you have cared for this animal and prior to your acquisition, if known.Any past illness, injuries, accidents or traumatic experiences?*Current ConditionAny health issues this animal has presently.Current health and/or behavior issues*Physical illness or injuries. Has your pet ever bitten anyone? Has it ever displayed any aggressive behavior?* Yes No If yes, please explain.Is your pet comfortable being touched all over its body?* Yes No If no, please explain where they are not comfortable being touched and the reactions to doing so.Name of Veterinarian and Practice For reference only. I will not contact your veterinarian unless you specifically ask me to.Current Veterinary DiagnosisCurrent Medications: Please list by name with start and end dates of each medication.Healing Session FocusPlease take the neccessary time to consider the following question.What needs do you and your animal have that you would like to be addressed during the healing session?*How did you first hear about Earth Horse Healing?* Would you like be added to my email list?* Yes, please I'm already on your list No, thank you To receive occasional emails about events and class announcements. Δ