Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Horse Name * Breed * Age * Sex * Gelding Mare Stud Veterinarian Consulted * Veterinarian Phone # * (###) ### #### Immunizations Current? * YES NO Worming Current? * YES NO Is this horse pregnant? * YES NO Does this horse have a history of seizures? * YES NO Has this horse had a Neurectomy? * YES NO Does this horse have an active infection? * YES NO Does the horse have any wounds? * YES NO Does this horse have EMP? * YES NO Is this horse on EMP medication? * YES NO Habits/Vices * Horse's Activities/Disciplines/Occupation? Problems/Conditions/Injuries? * Is the horse currently on any medications or been on any medications in the past three months? Please list: * Has this horse had any joint injections or regenerative therapies in the last 14 days? Please go into detail. * Has this horse had any vaccinations in the last 72 hours? * YES NO Have any other therapy modalities been used on this horse in the last 72 hours? Please list: * Any other medical history/information that I should be aware of? Thank you!