Client Intake Form

All information is confidential and will not be disclosed to any third party without written client consent.

Date

Month

Day

Year

First name

Last name

Phone

Mailing Address

Barn Address (where horse lives)

Horse Information

Horse's Name

Age

Gender

Mare

Gelding

Stallion

Height

Breed

Estimated Weight

Horse Health History

Veterinary Clinic:

Phone Number of Clinic

Date of Last Dental Exam

Date of Last Farrier Appointment

Hoof Maintenance (barefoot, trim, shoes, pads, wedges, time between appointments, etc.)

Currently, does your horse have any injuries or physical/performance limitations?

Enter injury diagnosis, date, and by whom diagnosed the injury.

Injury History

Enter injury diagnosis, date, and by whom diagnosed the injury.

Surgery History

Please include date and type of surgery

X-ray/ Ultrasound History

Enter type of imaging and date completed.

Goal of Care Plan

Has the horse ever received massage or PEMF therapy?

Yes

Below are a few of the benefits of equine massage. What are your top 3 goals for scheduling a session for your horse?

Please list exercise and stress reduction activities (including frequency).

Is your horse currently under other medical care besides general wellness care? (i.e. Chiropractors, PEMF, veterinary, physio, injections, etc.)

Please list current areas of concern on your horse including location to the best of your ability.

Are you okay with the use of linament and essential oils on your horse?

Yes

Policies

Client services and chart information are confidential. Written authorization is required from you to release any information.
Please turn off your cell phone for optimal relaxation for your horse.
Please reschedule your session if you will be more than 15 minutes late.
Your horse should be groomed, dry, and in a location where they are easy to access.
A 24-hour cancellation notice is required to avoid being charged for your session.
I understand that my therapeutic massage therapist or I may end the session at any time for any reason.

Client Release and Waiver of Liability

THIS IS A VOLUNTARY RELEASE OF LIABILITY. IT IS ALSO A BINDING ASSUMPTION OF RISK AND INDEMNITY CONTRACT.

In consideration of MDR Equine Therapy services treatment for my horse, I, the undersigned, on behalf of myself, my representatives, assigns, executors, and heirs, (collectively the "Client"), hereby agree as follows:

Services may include: Therapeutic Massage, PEMF therapy, and more. I understand that results are not guaranteed. I affirm no promises of efficacy or results made by MDR Equine Therapy Services regarding the outcomes or results of treatment.

Release of Liability and Hold Harmless

I hereby fully and forever release, waive and discharge MDR Equine Therapy Services, its owners, members, employees, agents, representatives, and assigns (collectively the "Releasees') from any and all claims, demands, actions, or causes of action of any kind, including statutory remedies, which I may or might have against the Releasees, arising from/or by reason of, any and all known and unknown, foreseen or unforeseen, bodily injuries, damage to property, and any consequences therefrom, which I may sustain due to Releasees' negligence.

I shall not bring any demand, claim, legal action against and/or sue the Releasees for any economic or non-economic losses due to bodily injury, death, or property damage as a result of the Releasees' negligence.

I hereby agree to indemnify and hold harmless the Releasees from and against any and all claims, liabilities, loss, damages, demands, actions, causes of action, including attorney's fees, costs and expenses of any kind, which may be made against them which arise out of the Releasees' services to my horse(s).

Entire Agreement; Construction; Attorney's Fees. This contract contains the entire understanding of the parties and may be modified only in writing. The invalidity or unenforceability of any term or provision shall not affect the validity or enforceability of the remainder of the provisions contained herein. This Agreement shall be interpreted and construed by the laws of Minnesota. In the event the Releasees retain an attorney to attempt to collect any sums due to them hereunder, to enforce any of their rights under this contract or state law, or to defend any action brought against them, in addition to any and all other remedies available to them under the law, they shall be entitled to recover reasonable attorney's fees and costs from the Participant (if they prevail).

I have carefully read this Release and I fully understand its content. I am aware that this is a Release of Liability, a waiver of legal rights and a contract between myself and the Releasees identified above. I sign this Release at my own free will. This Release shall be in full force and effect as of the date of this signature and for any and all future treatment and/or services.

I have read the policies, client release, and waiver of liability