Healing Reins Hippotherapy Application

This application is for Hippotherapy (PT/OT/Speech) at Healing Reins. The health professional assigned to you will ask you to complete additional forms and/or releases specific to their practice.
Participant Information
Participant Name *
Your answer
Date of Birth *
MM
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DD
/
YYYY
Age *
Your answer
Diagnosis: Primary *
Your answer
Diagnosis: Secondary
Your answer
Gender *
Height *
Your answer
Weight *
Your answer
Primary Phone (please tell us if it is cell or home ) *
Your answer
Email Address
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
School/Institution/Employer Name
Your answer
Is the Participant a *
Insurance Provider (include secondary, if applicable):
Your answer
Referring Therapist *
Your answer
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