INTAKE FORM
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Date:________________

CONTACT INFORMATION
Name:______________________________________________________________________________________

Mailing Address:______________________________________________________________________________ ___________________________________________________________________________________________

Shipping Address:_____________________________________________________________________________ ___________________________________________________________________________________________

Home Phone:__________________________________ Stable Phone:___________________________________

Mobil Phone: __________________________________ Caretaker’s Phone:_______________________________

Email address:__________________________________Fax number:____________________________________

Would you like me to send your treatment sheets via email □ or fax □ Who referred you?______________________________________________________________________________________

Animal Name: ______________________________________________________________________________

Species:____________________________________ Breed:__________________________________________    

Gender:____________________

Age:________ Became yours @ age:_______________

Veterinarian:_________________________________________________________________________________  __________________________________________________________________________________________

Veterinarian chiropractic or acupuncture:____________________________________________________________

Trainer:_____________________________________________________________________________________ ___________________________________________________________________________________________

Other Therapists:______________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

Horse or mules: shod □ or barefoot □

Use:
     pasture pal □ pleasure trail □ pleasure arena □western □ english □ endurance □ dressage
   □ jumping □ driving □ pulling □ AERC □ NATRC □ Competition show classes  Other:______________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
_
Do you have Small Animals: pet □ show □ work □ Competition  □ Show classes
___________________________________________________________________________________________

Other:______________________________________________________________________________________ ___________________________________________________________________________________________

Living Situation: (Small animals: indoor or outdoor, etc./ Horses: Alone, next to others or with others, stalled,
turned-out, paddock or pasture, boarded, at home, etc.) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

ll or small paddock quietly after the first treatment? A “buddy” nextdoor usually is necessary. ___________________________________________________________________________________________

Life History:_________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________  ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

Medical History:_______________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

Present Concerns and Observations::________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________


Diet (in detail, including all treats. Please attach copies of label ingredients:___________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

Any other information that might be helpful?__________________________________________________________  ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________



MAILING INSTRUCTIONS & PHOTO TIPS
     1.  Call Cali @ 916 663-4334 for mailing address.
     2.  She will call you when she receives the package, to set up your first phone consultation.
     3.  Send completed forms with the following: Small animals: any photo and small amount of hair. Tape the hair
          to a card and put it in a baggie with the name of your pet written on the outside.
 
Horses or mules:
     Photos:on bare level ground with the whole body in the photo.
          1) Full body side view - Tip: make sure his head is facing forward, not looking at the camera. Lower the 
              camera so the lens is opposite the rib cage/belly area. 
          2) Front view - Lower the camera so the lens is opposite the chest area. Try to square up the front feet if
              possible.
          3) Hind view - Lower the camera so the lens is opposite the rump area. Try to square up the hind feet if  
              possible.     
     Hair Sample: cut a couple of inches of mane or tail hair in a clump that is taped or tied together at one end.
          Put it in a baggie with the name of your horse written on the outside. Within a couple of weeks, follow up   
              with photos of the feet:
          Label each photo with the following: LF (left front) RF (right front) LH (left hind) RH (right hind). Clean
              and rinse or brush out all crevices of the feet Check for shadows. All details should be clear and visible.
           Standing photos should be on a bare, level, hard surface. Include the full foot, pastern, fetlock and a little
             of the cannon bone.
      Tip:1.  Hold the camera down near the ground for the side and front views.
          1) Side view of each foot separately.
          2) Front view of each foot separately
          3) Bottom/sole of each foot separately.
     Tip 2. : Hold the camera lens parallel to the sole of the foot. It helps to have another person hold the foot for
           you while you use the camera. Make sure the whole foot is in the photo.