Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Preferred appointment reminders
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Veterinarian's Clinic Name
Primary Veterinarian's Phone
(###)
###
####
Primary Veterinarian's Email
Would you like us to share your records with your primary veterinarian?
Name of Animal
*
Species
*
Canine
Equine
Bovine
Feline
Ovine
Caprine
Other
Breed
*
Gender
*
Mare
Gelding
Stallion
Male
Neutered Male
Female
Spayed Female
Age
*
Current Weight
Discipline/Use
*
Is your animal insured?
*
If yes - please include details on insurance coverage and record transfer in the text box below.
Insurance information
Animal's Physical Address
*
Please include any specific instructions to find your location via GPS. (Ex. House is down the lane just past the big blue barn)
Reason for referral including all known history of injuries, surgeries, or medical conditions.
*
Please be as detailed as possible.
Date of Onset/Injury/Surgery if applicable
MM
DD
YYYY
Have you pursued any diagnostics (e.g., X-rays, MRI, ultrasound)?
*
If yes, please list and bring copies or arrange for transfer.
Current Medications or Supplements:
*
Known Allergies or Sensitivities (medications, food, etc.):
*
Current Vaccination & Deworming Status
*
Rehabilitation Goals
*
What are your primary goals for your animal's rehab? (check all that apply)
Animal Handling and Behavior
*
Is there anything else that you think we should know about your animal to prepare for his/her first visit? (Ex. “Go slow when picking up feet, will bite if you touch X body part, highly food motivated, etc).
Current Farrier Schedule (Equine)
Does your horse have any vices (e.g., cribbing, weaving, kicking)?
This helps us to better put together a home exercise plan if indicated for your animal.
What is your current turn out routine?
Include details like access to pasture, size of paddock if possible, and stall arrangements.
