NEW HORSE HISTORY FORM

I understand that Acuscope and Myopulse Therapy or other modalities are never a replacement for proper veterinary care. I understand that SL Acuscope and Myopulse will not diagnose conditions, attempt any adjustments/musculoskeletal manipulations or prescribe medications, nutraceuticals or supplements for my horse. If my horse is currently being seen by a veterinarian, I have cleared this work with the attending veterinarian to ensure Acuscope and Myopulse Therapy is at this time appropriate for this horse.

Your Signature

Date

CANCELLATION POLICY: Please be advised that cancellations made up to 48 hours before a scheduled appointment via text or phone call will be processed without a penalty. Cancellations made 48 hours or less before an appointment will be subject to a charge of half of the session price. A no show with no cancellation made will result in full charge.

Name of Owner

Email

Breed

Age

Phone Number

Horse Name

Sex

Height

If the horse is a male, when was the sheath last addressed?

If the horse is a female, has she previously foaled? Does she have issues while in season and/or has had a reproductive exam?

No

Yes

If yes, please state how many foals and/or any issues/concerns

If the horse is female, is she currently in foal?

No

Yes

Has your horse been denerved (Neurectomy)?

No

Yes

Has your horse been diagnosed with cancer?

No

Yes

Has this horse ever bitten/attacked anyone (Human or Horse)?

No

Yes

Habits/Vices

Current Veterinarian or Vet Hospital

Phone

How long have you owned/leased this horse?

What are your goals for this horse?

What has the horse done as far as other riding disciplines before you owned this horse?

What are the horse's activities/duties/occupation currently?

Do you have any information as far as previous and current history, performance and health issues?

When was the last time your horse was seen by a veterinarian and why?

Is your horse on any current medications, nutraceuticals or supplements?

What is your horses feeding program?

What is the current housing or turnout for your horse?

When was your horse last shod or trimmed and by whom?

When were the teeth last addressed and by whom?

Have any other therapeutic devices or modalities been used on this horse (Ex. PEMF, Shockwave, Laser, Massage, Chiropractic, Etc)

No

Yes

If yes, what and when?

Immunizations current?

No

Yes

Worming current?

No

Yes

Is this session intended as part of your horse's well being protocol or do you have specific concerns and areas you would like addressed?

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!