Equine-form — True Kneads Animal Massage

Equine Intake Form.

Your contact information and your horse’s health history.

Your Name

First Name

Last Name

Phone Number

(###)

###

####

Email

Preferred Method of Contact

Email

Phone

Text

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Horse's Name

Horse's Age (approximately)

Sex

Tell me about your horse (breed, activities, known medical conditions, trauma, etc).

Veterinarian

First Name

Last Name

Veterinarian's Phone Number

(###)

###

####

Physical Observations

Have you noticed if your horse prefers to rest on one side over the other? Have you noticed any changes in their movement or gait (walk, trot, canter)? Are there new or existing behaviors that suggest they may have some discomfort (head shy, dragging feet, skittish, etc)?

Is there anywhere your horse does not like to be touched?

Permission to do bodywork

By checking the box below, I give Katherine Berry permission to perform bodywork on this horse. I understand massage or other modalities are never a replacement for proper veterinary care. I understand that Katherine Berry, as a Small Animal Massage practitioner will not diagnose conditions, attempt any adjustments/musculoskeletal manipulations or prescribe medications, nutraceuticals, or supplements for my animal. If a veterinarian is currently seeing this animal, I have cleared this work with the attending veterinarian to ensure bodywork is at this time appropriate for the dog or cat. I affirm that I have given all relevant information and will update you when new information is acquired. *

Yes

No