Equine Client Info Form | Thera-Vet Acres

OWNER/CAREGIVER

Please provide the information below as completely as possible. All information is strictly confidential

Horse's Name*

Owner / Caregiver*

Co-owner / Significant Other

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone*

Additional Phone 1

Additional Phone 2

Email*

How did you hear about us?

HORSE INFORMATION

Breed*

Age / Birthdate*

Gender*

Color / Markings

When did you obtain your horse?

VET/STABLE INFORMATION

Veterinarian

Clinic Name

Where is your horse stabled?

What is the stable's address?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DAILY CARE

Brand/Type of Feed:

How much and how often fed:

Medications (when given with amounts):

Supplements (when given with amounts):

Allergies:

Farrier:

Date last shod/trimmed?

Shoes (select one):

Front Only
Rear Only
All Around
Barefoot

When were the teeth last floated/checked? By whom?

***It is important that if your horse has not had routine Veterinary Spinal Manipulation Therapy ( VSMT formerly chiropractics) previously, that no major changes to their feet and/or teeth has been done within 10 days of their first VSMT evaluation. We also do not recommend competing with your horse within 5 to 7 days after their first adjustments as there is a slight possibility of them being sore from an initial treatment.

HISTORY/TEMPERAMENT

Any vices? (towards humans, kicking, biting etc.):

Describe your horse's typical temperament:

Any history of past injury, lameness or illness?

Current Issue:

Any recent x-rays, blood work or other diagnostics performed for this condition?

Has the horse previously had a VSMT adjustment?

How did they respond?

Has the horse previously had acupuncture?

How did they respond?

ADDITIONAL INFORMATION

Please give us any additional information that you feel could be beneficial to us in helping your horse.

Discipline:

Do you compete?

How exercised?

How often exercised?

Turnout (where and for how long)?

STATEMENT OF OWNERSHIP

Is there someone whom you give permission to make decisions on treatments and modalities performed (ie trainer)? If so, please list them here:

By checking below you certify that you are the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed. Confirmation*

I agree.

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