Intake Form

Thank you for choosing equine equilibrium for your horse's physiotherapy needs.  THESE FORMS ARE QUITE COMPREHENSIVE AND ALLOWS US TO PROVIDE THE BEST POSSIBLE CARE FOR YOUR BELOVED COMPANION.

I am a professionally licensed, insured and nationally board certified practitioner. I adhere to the highest ethical standards of practice and compliance with national and state laws regarding my profession. Please note that my care is not a substitute for appropriate veterinary care.

EQUINE CLIENTS: pLEASE FILL OUT THE FORM BELOW.  

ALL OTHER CLIENTS: PLEASE SCROLL DOWN AND FILL OUT SECOND FORM FOR SMALL ANIMALS

Date *
Date
Name *
Name
Please describe any previous or ongoing hoof issues, such as thrush, white line disease, laminitis, navicular syndrome, thin soles, frequent abcesses, frequent throwing shoes, how often feet are trimmed/shod
Please check boxes if your horse is sensitive to being: *
Please let me know if your horse has ever foundered, bowed a tendon, any fractures, injured tendons or ligaments, had stifle or hock issues, if you get your horse injected with steroids for any reason, etc.
Consent for Treatment *
As per my professional licensing, I am required to collect Consent for Treatment. Do you give consent for me to provide therapeutic services for your animal? If you are not the owner of this animal, you will be required to provide proof of owner consent.
Please type your name below as an e-signature for consent for treatment
Name *
Name
Please select. If you choose "other", please add in the species to the Animals Name Example: Thumper-rabbit
If a cross, please describe your best guess.
Inside only/outdoors only, kenneled, etc. Please also include if there are other animals in home.
Please also list if there have been surgeries or major diagnostic work.
Example: Kidney disease, diagnosed 3 yrs ago... or hip dysplasia, confirmed 6 months ago, etc.
Example: eating rocks/trash; small dogs leaping off furniture; instigating rough play with bigger animals
Example: hates tail touched, nervous about men, etc.
Consent for treatment
As per my professional licensing, I am required to collect owner consent for treatment for all animals I treat. Do you give consent of treatment for this animal? If you are not the owner, you must provide a written consent for treatment from the owner