Intake Assessment Form
Thank you for expressing your interest in booking an appointment for your horse! Please fill out the form below, and I will reach back to you with confirmation for your appointment. If you have any reports from other practitioners (veterinarian, chiropractor, farrier, etc.), and would like to share them, please email them to aplusequinemassage@gmail.com
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What is your name? *
Are you a new or existing client?

What is your phone number? (for contact purposes)
What is your email
Full address of location of horse 

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Horse's Name


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Horse's Breed
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Horse's Age

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Is your horse a mare, gelding, or stallion
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Years that you have owned this horse?



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Who is your vet? Name and contact info
Who is your farrier? Name and contact info

Name and contact info of anyone else on your horse's health team (nutritionist, bodyworker, chiro, pemf, etc.
Is your horse shod or barefoot? What is the length of the trim/reset cycle? Date of last trim?
Discipline(s)? *
Describe your competitive ride season. Skip this question if you are not competing.
Average rides per week


Describe your horse's diet
Reasons for seeking bodywork


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What are your goals with your horse?

How did you hear about A Plus Equine Massage? *
Required
Is your horse currently receiving any other form of bodywork or treatment from a veterinarian for an ongoing injury or issue? Please describe below. If horse is currently undergoing veterinary care for a lameness, injury or other issue, please provide name and contact info for them so Ashley Stinson dba A Plus Equine Massage can obtain clearance from them to perform bodywork.
Please describe any previous injuries, diagnoses, issues, bodywork, vet work, etc. that your horse has had
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I am allowing Ashley Stinson dba A Plus Equine Massage and all persons correlated to the company to assess, treat and customize a program for my horse. I agree to hold them harmless for all incidents that may occur during the time that Ashley Stinson dba A Plus Equine Massage is present, or during the time that I am carrying out the assigned program. *
I understand that my horse may or may not have a full recovery as intended, and agree not to hold Ashley Stinson dba A Plus Equine Massage responsible for any lameness, injury, lack of performance, or other unintended results. *
I agree to seek veterinarian advice for any applicable circumstances or scenarios, and understand that Ashley Stinson dba A Plus Equine Massage's advice and services do not replace veterinary care and are not confirmed diagnoses of any injuries or conditions. *
I agree to allow Ashley Stinson dba A Plus Equine Massage to take pictures and videos of my horse, primary as a method of maintaining records, but I also understand that the pictures and videos may be shared for training purposes with other massage therapists or students in classes or on social media. *
Do you acknowledge that payment is due at the time of appointment via cash or etransfer?
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Do you consent to having your email address added to our newsletter subscription (you can unsubscribe at any time)?
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Please write your first and last name below, serving as your electronic signature for the above waiver

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Is there anything else you would like to add?
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