Equine Therapy Intake Form
Please take the time to fill out this form in order for me to best assist you and your horse.
電子郵件 *
Your Full Name *
Phone Number *
Horse’s Name
Where does your horse live? Please provide exact address. If outside of Langley/Aldergrove/Abbotsford additional travel fees apply. Fees are calculated based on your location.  *
What is the reason you are seeking an equine therapy appointment (either online or live) *
必填
Please briefly describe any issues or concerns you would like addressed during your horses assessment.
What is the sex of your horse? *
How old is your horse? *
What is your horse's predominant occupation (pleasure, competition, retired, etc.) *
Has your horse ever had any of the following? Check all that apply. *
必填
Does your horse appear to be in pain? *
What type of environment does your horse live in? Check all that apply. *
必填
Does your horse live in a herd or have group turnout on a regular basis (please specify). *
What is your feeding practice? (i.e. 24-7 free flow, slow feeders, timed feeding etc.) *
Does your horse get grains? If so, please specify type and daily amount. *
When was your horse last trimmed or shoed? *
When was your horse last wormed? Please specify type, dosage, frequency. *
When were your horse's teeth last done? *
What type of tack do you use (check  all that apply) *
必填
Has your tack been fitted by a Certified Saddle Fitter? If so, when? *
Please rate your horse's activity level (low 0-3, mod 4-6, high 7-10) *
Please list any other previous injuries your horse has sustained (how long ago, did you call vet, any meds prescribed etc.) *
Are you currently competing with your horse and if so when is your next competition (list what discipline) *
How often do you work with your horse on the ground? (times per week, what are the goals) *
Has your horse received bodywork before? Please specify (Chiro, physio, massage, etc) and how did your horse respond to treatment in the past? *
Is your horse on any medications? (i.e. bute, previcox, prascend, metformin, etc) Please specify for how long your horse has been on these medications and what is the daily dosage. *
Please list your veterinarian info (name, contact info, clinic) *
Anything else you would like to add? *
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