Intake — Equine in Balance

intake form

If there is more than one animal being treated please separate information with a “ / “

EQUINE IN BALANCE  rehab for body & soul  Claudia Loferer (CEMT)  (902) 398 - 0053 claudia@equineinbalance.com

Date

YYYY

Owner's Name

First Name

Last Name

Address

Phone

(###)

###

####

Barn Name

Barn Address

I, the undersigned, as the owner/guardian of the animal listed above, do hereby give consent for soft tissue therapy.

Unless the therapist receives written notice from the owner named above, this consent to work on said animal will allow for continuing soft tissue and VR session (if permissible) without continual written consent from the owner/guardian. I understand that following soft tissue and VR work, the animal may exhibit signs of soreness for up to 48 hours, and this is a normal result of the work. Issues that are latent, may show themselves. Examples include but are not limited to an abscess that has not shown itself, may erupt; a low grad cold/flu may become high grade resulting in high temperature, excessive mucus expulsion, etc. post soft tissue work. Any metastasizing tumors may/can spread. Any pictures and videos taken are the exclusive property of the therapist and may be used for any purpose. I agree to pay for all expenses incurred for sessions which have been indicated above. Any cancellation under 24 hours in advance is subject to a $20 fee; any no-show is subject to the full fee incl. mileage. Any returned cheque is subject to a $25 fee.

Horse's Name / Breed / Sex

Colour / Age / Height

Weight / Feed / Deworming Schedule

Vices

Veterinarian / Date of last visit

Farrier / Date of last visit

Saddle Type / Notes on Saddle Fit

Showing

Pre Existing Conditions

Owner's Observations / Complaints

Please click to give consent.

Please print your name and the date to support above consent.

equine in balance - Rehab for body & soul

this website was built with a lot of love for horses

Claudia travels to you, her office address is 308 Veinot Road, New Canada, Nova Scotia, Canada B0R 1E0 (902) 398.0053

Website Created by: Deborah Spilman - Master in Business Marketing (506) 461 1971 digitalspilman@gmail.com