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Intake Form
Prior to your horse receiving their first treatment, please fill out this form. If the vet or chiropractor (or any other practitioner) has seen your horse for any injury applicable to their massage needs, please forward the records to
melsequinemassage@gmail.com
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Email
*
Your email
Owner's Name (First and Last)(required)
Your answer
Email (required)
Your answer
Horse's Name (required)
Your answer
Horse's Breed (required)
Your answer
Horse's Age (required)
Your answer
Years that you have owned this horse (required)
Your answer
Discipline(s) (required)
Your answer
Describe your competitive season (circuit, division, length of season). Skip this question if you are not competitive.
Your answer
Average rides/week? Does this decrease over winter? (required)
Your answer
Main reasons for seeking massage therapy or other services (describe current issues, as well as past injuries and problem) (required)
Your answer
I am allowing Mel's 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 Mel's Equine Massage is present, or during the time that I am carrying out the assigned program.(required)
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Agree
Disagree
I understand that my horse may or may not have a full recovery as intended, and agree not to hold Mel's Equine Massage responsible for any lameness, injuries, lack of performance, or other unintended results. (required)
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Agree
Disagree
I agree to seek veterinarian advice for any applicable circumstances or scenarios, and understand that Mel's Equine Massage advice and services do not replace veterinary care and are not confirmed diagnoses of any injuries or conditions.(required)
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Agree
Disagree
I agree to allow Mel's Equine Massage to take pictures and videos of my horse, primarily 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.(required)
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Agree
Disagree
Please write your first and last name below, serving as your electronic signature for the above waiver.(required)
Your answer
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