Intake Form

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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

Email *

Owner's Name (First and Last)(required)

Email (required)

Horse's Name (required)

Horse's Breed (required)

Horse's Age (required)

Years that you have owned this horse (required)

Discipline(s) (required)

Describe your competitive season (circuit, division, length of season). Skip this question if you are not competitive.

Average rides/week? Does this decrease over winter? (required)

Main reasons for seeking massage therapy or other services (describe current issues, as well as past injuries and problem) (required)

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)

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)

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)

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)

Please write your first and last name below, serving as your electronic signature for the above waiver.(required)

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