Owner
*
First Name
Last Name
Home Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Co-Owner / Leaser (if applicable)
First Name
Last Name
Co-Owner / Leaser Address
if different from above
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Co-Owner Phone
(###)
###
####
Co-Owner / Leaser Email
If Co-Owned-Do Both Owners Have Medical Signing Privileges?
Yes
No
If No, Who Has Signing Privileges?
Trainer (if applicable)
First Name
Last Name
Trainer Phone
(###)
###
####
Your Horse's Name
*
Your Horse's Show or Registered Name
Date of Birth
*
Breed
*
Sex
*
Mare
Gelding
Colt
Filly
Stallion
Is your horse used for breeding purposes?
*
Yes
No
Is there a chance your mare is in foal?
Yes
No
Currently Stabled at:
*
Facility / Farm Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is this your horse's primary home?
*
Yes
No
Seasonal
If your horse moves seasonally, please describe below
Primary Veterinarian
*
First Name
Last Name
Vet Phone
*
(###)
###
####
Vet Email
Additional Vet (if applicable)
First Name
Last Name
Phone
(###)
###
####
Email
Blacksmith / Farrier
*
First Name
Last Name
Blacksmith / Farrier Phone
(###)
###
####
Blacksmith / Farrier Email
Blacksmith / Farrier Cycle
*
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 weeks
8 weeks
Barefoot / Shod
*
Barefoot
Shod in the front
Shod all around
Seasonal Shoe cycles
Date of last trim / reset
Date of last dental exam / support
*
Equine Dentist (if applicable)
First Name
Last Name
Equine Dentist Contact info
Additional Health Team
Please List Any Additional Horse Health Team Members(Chiro/PEMF/Massage etc) And Details Below
Medical History
*
Does your horse have any major medical history or current medical concerns? If yes, please describe below and not any current treatment plans and or medications ( including supplements)
Personality
*
How would you best describe your horse’s personality, both with people and with other horses?
How is your horse turned out?
Individual
With one other horse
Group of 3-5
Group of 5-10 horses
Large herd 10+
Diet
*
What does your horse currently eat? Include all supplements not listed above in medical history
Do you ride your horse?
*
Yes
No
Activities
If you don't ride, what sort of activities do you do with your horse and how often
Disciplines
If you ride, what disciplines do you do?
Riding Frequency
If you ride, how often and for how long do you ride?
Do you compete with your horse?
*
Yes
No
Competion
If you compete, how often and where do you travel?
What are the things that your horse currently does really well?
*
What are the things that your horse currently struggles with?
*
What are your goals for your horse this year?
*
More detail
*
Is there anything else you would like to mention about your horse that we have not yet covered? If so feel free to use the space below. All details and questions are welcome- the more we know the more we can assist the body
Informed Consent
*
BODYWORK CONSENT I, the undersigned, do hereby acknowledge that I understand, to the best of my ability, that Equi-Bow (Craniosacral,Bowen), Equi-Tape, and WEBB techniques can help facilitate change and healing within the body. I understand that after my horses assessment we will discuss the session plan before proceeding. I acknowledge that equine bodywork support does not replace veterinary diagnosis or care. I agree to seek licensed veterinary care for my horse for any health concerns I have. I hereby voluntarily consent to having the Certified Practitioners of North of 9 Equine & Canine Bodywork assess and work hands-on with my horse.
First Name
Last Name
Payment Agreement
*
I acknowledge that I have received and reviewed the current rates for my pet's bodywork session.I acknowledge that payment is due within 30 days of my billing date and subject to a late payment fee of $25 per month. Payment options include cash, e-transfer (office@northof9bodywork.ca) or credit card (Invoice link)
First Name
Last Name
