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ENP Equine Massage Intake Form

GENERAL INFORMATION

Client Name

Client Age

Discipline

Client Breed

Client Height

Owner Name

Phone

Email

Mailing Address


RELEVANT HISTORY On a scale of 1-10 with 10 being extremely high/heavy, how would you describe the current workload? Consider frequency and duration of work as well as intensity.

Have you ever had any diagnostic procedures completed on this horse? Where on the body? Why? What did the results show?

Is there any known history of lameness, injury, or other health concerns aside from anything listed above?

What are your current concerns with regards to this horse's health and performance? Consider reluctance, noticeable imbalances, discomfort, or behaviours.

Has your horse ever received massage/bodywork before? If yes, approximately how long ago?


WAIVER AND RELEASE OF LIABILITY

Equine Massage Therapist: Erin O'Drowsky 226 377 0244 [email protected]
The Owner:
The Client:
I, The Owner listed above, am allowing my horse, The Client listed above, to receive body work from the Equine Massage Therapist. I understand that massage is not a substitute for medical treatment or medications, and that it is recommended that I work with my veterinarian for any medical conditions that my horse may have. I understand that body work sessions are for the purpose of, but not limited to: improved circulation improved relaxation and stress reduction improved lymph drainage relief from muscular and mental tension improved range of motion decreased recovery time improved respiratory health improved digestive health
I understand that the Equine Massage Therapist cannot diagnose illness or disease and cannot prescribe medications. I understand that any information provided by the Equine Massage Therapist is for educational purposes on, and is not diagnostically prescriptive in nature. I have informed the Equine Massage Therapist of all the horse's known physical conditions, limitations, medical conditions, and medications. It is the responsibility of the owner to update this information with the Equine Massage Therapist and to contact a veterinarian if the horse's physical condition, limitations, medical condition, or medications should change.
By signing this release, I hereby waive and release the Equine Massage Therapist listed here from any and all liability - past, present, and future - related to massage and bodywork.
Owner Name Printed:

Date

Signature

Signature