Date

MM

DD

YYYY

Gaurdians name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Prefered contact method *

Phone call

Text

Email

Barn owner's name *

First Name

Last Name

Barn address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Veterinarian *

First Name

Last Name

Veterinarian's phone *

(###)

###

####

Permission To Perform Bodywork *

By checking the box below, I give Harbor Equine Bodywork permission to perform bodywork on this horse. I understand massage or other modalities are never a replacement for proper veterinary care. I understand that the Equine Body Worker will not diagnose conditions, attempt any adjustments/musculoskeletal manipulations or prescribe medications, nutraceuticals, or supplements for my horse. If a veterinarian is currently seeing this horse, I have cleared this work with the attending veterinarian to ensure bodywork is at this time appropriate for the horse. I affirm that I have given all relevant information and will update you when new information is acquired.

I agree