Physician's Statement
Dear Health Care Provider:
Your patient is interested in participating in the Spirit Open Equestrian Program. In order to safely provide this service,
we need your help. Please answer the questions below and sign this form to support our processes.
Thank you for your time

Spirit Team
www.spiritequestrian.org
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This form MUST be signed by a licensed physician
Name of patient/participant of Equine Assisted Activity / Equine Assisted Psychotherapy/ Therapeutic Riding or Equine Assisted Learning *
Primary condition indicated for Equine Assisted Activities *
Secondary and other conditions to be considered
Date of birth *
MM
/
DD
/
YYYY
Weight *
Height *
Possible contraindications
Your patient is interested in participating in supervised equestrian activities.  In order to safely provide this service, our center requests that you complete/update this form.  Please note that the following conditions may suggest precautions and contraindications to therapeutic horseback riding.  Therefore, when completing this form, please note whether these conditions are present, and to what degree.
*
Comments
Date of Onset
MM
/
DD
/
YYYY
Past/prospective surgeries *
Medications *
Seizure type *
Controlled? *
Date of last seizure
MM
/
DD
/
YYYY
Shunt present? *
Date of last revision
MM
/
DD
/
YYYY
Special precautions, diets/needs *
Can s/he participate in mounted activities (Therapeutic Riding)? *
Required
May participate except for: *
Mobility
Independent Ambulation? *
Assisted ambulation? *
Wheelchair?
Clear selection
Braces/assistive devices
If  patient has Down syndrome, can you provide x-rays for Neurological symptoms of atlanto-axial instability? *
Tetanus shot?
Clear selection
Date
MM
/
DD
/
YYYY
Please indicate current or past difficulties in the following systems/areas, including surgeries
Auditory
Visual
Tactile sensation
Speech
Cardiac
Circulatory
Skin
Immunity
Pulmonary
Neurological
Muscular
Balance
Orthopedic
Allergies
Learning disability
Cognitive
Emotional/psychological
Pain
Other
To my knowledge, there is no reason why s/he cannot participate in supervised equestrian activities *
Required
Expected benefits from Equine Assisted Activities *
Signature - By typing your name here, you are consenting to the use of your electronic signature in lieu of an original signature on paper.  You have the right to request that you sign a paper copy instead. However I understand that the medical information above will be taken against the existing precautions and contraindications.  I concur with a referral of the patient to a licensed/credentialed health professional (e.g., PT, OT, Speech, Psychologist, etc.) in the implementations of an effective equestrian program. *
Name/Title *
MD, DO, other *
Date *
MM
/
DD
/
YYYY
License/UPIN number *
Thank you!
Thank you very much for your assistance.  If you have any questions or concerns regarding this patient's participation in therapeutic equine activities, please feel free to contact me as indicated below.
This e-mail form is intended only for the use of the individual or entity;  it is confidential and disclosure is prohibited.  If you have received this e-mail in error, please notify the sender immediately either by e-mail or phone and delete this e-mail from your computer.
Sincerely,
Davorka Suvak
Spirit Open Equestrian Program, Inc.
Executive and Program Director
703 600 9667
spiritoep@spiritequestrian.org
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