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.

"*" indicates required fields

Name of Owner*

First Last

Address*

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

Email*

Phone number you'll call me from*

Your Skype or Teams phone number if calling from outside 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

Please choose all times you are available in Eastern Time, thank you.

Description

Name of Animal*

Species*

Common name is fine.

Breed*

Color

Sex*

Female

Spayed Female

Male

Neutered Male

Age*

The Age Specified Is:*

Actual

Estimate

Acquisition

Year of Acquisition*

Where did you obtain the animal from?*

Please tell me about the animal's prior situation, if known:*

Lifestyle and Management

Daily 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 History

Include 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 Condition

Any 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

If yes, please explain.

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

Yes

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 Diagnosis

Current Medications: Please list by name with start and end dates of each medication.

Healing Session Focus

Please 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.