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Intake Form
Please submit form 24 hours prior to scheduled session
* Indicates required question
Name
*
Your answer
Email
*
Your answer
Address
*
Your answer
Barn Address (if different from home)
Your answer
Phone number
Your answer
Horse's Name
Your answer
Breed
Your answer
Age
Your answer
Height
Your answer
Gender
Mare
Gelding
Stallion
Clear selection
Discipline / Use
Your answer
Typical Work Week-- duration and number of work sessions per week
Your answer
Diagnostic History-- radiographs / ultrasounds & findings
Your answer
Other lameness/ injury history
Your answer
Other health / injury history or limitations
Your answer
Medications / Supplements (include reason for taking)
Your answer
Veterinarian
Your answer
Farrier
Your answer
Dental Provider and date of last dentistry
Your answer
What are your current concerns about your horse's health and performance?
Your answer
Other information you would like to share regarding handling/ treatment of your horse
Your answer
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