New Patient Intake

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New Patient Intake

Thank you for choosing Cypris Bodywork & Wellness. Please fill out this form to the best of your ability.

Email *

Name First & Last *

Preferred Pronouns

Home Address *

Phone Number *

What brings you in to Cypris Bodywork & Wellness Today? *

What is your horse's name? *

What is your horse's date of birth? *

What is your horse's breed? *

Mare

Gelding

Stallion

Clear selection

What is the approximate weight and height of your horse? *

Please list your equine care team's information: i.e. the veterinary, chiropractic, acupuncturist and/or massage therapist information you are currently working with.

Has equine ever had massage therapy before? If so, please enter the date of their last massage, if not please enter No or N/A. *

What are the reasons for your equine's visit today? *

What results would you like to see from your equine's treatment? *

Please describe exercise, activity and frequency of these. *

Is your equine under veterinary care currently? If so, please describe:

Please list any medications or supplements your equine is currently taking. *

Please list any injuries, surgeries, illnesses, or accidents your horse has experienced:

Please describe any health challenges or other conditions/concerns not listed above *

Photo/Video Use Consent. Please Check all that apply. *

I consent for the photos/videos of my horse to be used for medical record keeping purposes.

I consent for the photos/videos of my horse to be used for sharing with my vet or other equine health care providers..

I consent for the photos/videos of my horse to be used for educational purposes.

I consent for the photos/videos of my horse to be used for marketing and advertising purposes.

I do not consent to any photos or videos

Required

I acknowledge and will adhere to the 48 hour cancelation policy of Cypris Bodywork & Wellness. Any cancellations made less than 48 hours before agreed upon appointment time will be charge the full visit fee of $150. *

Yes

I acknowledge that my appointment starts at the time it is scheduled, and ends promptly at the agreed upon appointment duration. No extra time is given for scheduling or payment. *

Yes

By entering my name in the space below I acknowledge It is my choice to for my equine to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for my equine's massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions of my equine that I am aware of and will inform my practitioner of any changes in their health status. Please type name and date signed below. *

I will participate fully as a member of my equine's healthcare team. I will make sound choices regarding my sessions’ plan based upon the information provided by my massage therapist. I agree to participate in my own equine self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my equine's well-being is being compromised. *

Yes

Out of an abundance of care and caution, Cypris Bodywork & Wellness requires both therapist and patient to wear a mask at all times, regardless of vaccination status. This is a policy based on the population we specialize in serving, including the immunocompromised and cancer patients. I agree to comply with this mask policy. *

Yes

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