The Horse Physio - Delivering care with expertise since 1992
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- About the Owner
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Owner's Details
Name of Owner
(Required)
Email
(Required)
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Home Phone
Mobile Phone
(Required)
How did you hear about Sue?
Source of referral
Your Emergency Contact
Who should I call if something happens to you?
Emergency Contact Number
Their contact number
Consent to treatment?
(Required)
Yes
No
Is Horse Insured?
Yes
No
Insurance Company Details
Horse's Details
Name of Horse
Gender
Mare
Gelding
Stallion
Age of Horse
Height
Colour
Breed
Owned since
Use
Vetted for Purchase
Not Vetted
3 Stage
5 Stage
X-Rays?
Risk Assessment, Likely to:
Check all that apply
Kick
Bite
Barge
Be nervous
Other
Describe other risks
Yard Address
Street Address
Address Line 2
City
ZIP / Postal Code
Treated at
Street Address
Address Line 2
City
ZIP / Postal Code
Vet's details
Name of Vet
Practice
Phone
Last seen by Vet
Last Wormed
Last Vaccinated
Any reaction to worming or vaccination?
Has Vet seen problem?
Yes
No
Veterinary Consent
Written (requested)
Verbal (via owner)
Subjective Assessment
History of present complaint
(what would you like to achieve from today’s session / long term, what is your horse’s previous history?
Past medical / behavioural history
what do you know of your horse’s history
Diet
what does your horse eat?
Allergies
does your horse have any allergies that you know of?
Medication
is your horse on any medication
Neutraceutricals
does your horse have any diet supplements
Does your horse have any concerns with
Headshaking
catching
clipping
loading
saddling
rugging
girthing
mounting
Does your horse suffer from:
Headshaking
Runny eyes
Runny nose
'mare-ish' behaviour
ear shy
head shy
Environment
does your horse live in stable or paddock, alone or in company, does he lie down and / or roll right over, describe schooling / hacking area
Exercise routine
how often and how long, what discipline, what level are horse and rider, do you have a regular instructor, what arena surface, hilly or flat hacking
Behaviour
describe your horse’s normal behaviour, any recent changes, any problems, any previous help with these issues
Farrier
(name of farrier, type of shoes, frequency shoeing/trimming, when due, any behavioural problems or resistance to being shod / trimmed
Saddler
(name of saddler, type of saddle, when last checked, any problems or changes, type of bit, type of noseband, additional tack such as martingales
Teeth
name of dentist, last checked, any problems
Previous physio / chiro / osteo / massage
last visit, name and qualifications of practitioner, any findings and subsequent changes
Expectations of assessment and treatment
To ensure high standards of treatment and care I will:
explain to you how physical therapy can help your animal, including the benefits and risks associated with treatment.
undertake an assessment prior to commencing any treatment and explain the results of this assessment to you.
explain the treatment to be provided during each session.
maintain contact with your veterinary surgeon during the course of treatment if appropriate.
upon completion of treatment, appropriate management advice will be provided.
If, for any reason, you are unhappy about your treatment, you:
should inform me immediately to see if the matter can be resolved informally.
are entitled to make a complaint to The Horse Physio (Sue Palmer), ACPAT (with regards to Sue Palmer) or Intelligent Horsemanship (with regards to Sue Palmer). Complaints are treated seriously and your complaint will be dealt with promptly and professionally in accordance with my Complaints Policy.
can view your treatment record at any time.
can refuse further treatment.
Declarations
Consent
(Required)
GDPR – Under data protection rules, and the law governing the personal information that you give on this
form. We are required to keep your information (stored on paper or electronically) for a minimum of
seven years. The information may be shared with your Vet as shown on this form. Our Privacy policy can be found on the website www.thehorsephysio.co.uk
I agree to the privacy policy.
Vet Consent
(Required)
I confirm that I have contacted my vet and have received consent for physiotherapy treatment for my horse.
Declaration
I, as
(Required)
the owner of the above animal
the agent for the above animal
Give my consent for
(Required)
physiotherapy assessment
and appropriate treatment
For the above animal, I sign to agree that I understand that there are risks involved when handling and working with horses. I do not hold Sue Palmer or The Horse Physio responsible for any damage which may occur to myself, my horse or my property whilst she is working with my horse.
(Required)
Signed on Date
(Required)
Day
Month
Year
Name
This field is for validation purposes and should be left unchanged.
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