Small Animal Intake Form Please fill out and submit this form at least 48 hours prior to your appointment. The information you provide is held as private and will not be shared without your expressed permission. ONLY THE FIELDS MARKED WITH A RED ASTERISK ARE REQUIRED. Contact InformationName of Owner* First Last Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone number you'll call me from*Skype name, if you live outside the USA Email* Would you like to be added to my email mailing list?* Yes, please No, thanks For occasional emails with news about upcoming classes and events.Appointment availability, eastern time* Weekday mornings: 9-11 am ET Weekday afternoons: 1-4 pm ET Weekday evenings: 6-7 pm ET Please select the times when you can be at home with your pet.DescriptionName of Animal* Species* Common name is fine.Breed* Color Sex* Female Spayed Female Male Neutered Male Age* The Age Specified Is:* Actual Estimate AcquisitionYear of Acquisition* Where did you obtain the animal from?*Please tell me about the animal's prior situation, if known:*Lifestyle and ManagementDaily Diet: Please be specific: wet or dry, brand name with flavors.*Daily Supplements and Treats: Please give brand names.*Vaccinations: History and Present Routine*Please list vaccinations and include frequency of shots. Please describe your animal's lifestyle; i.e. access to the outdoors and indoors or shelter.*Exersize ProgramDoes you have a regular exersize program for your animal? If so, please explain.Medical HistoryInclude anything historic and significant that has occurred while you have cared for this animal and prior to your aquisition, if known.Any past illness, injuries or accidents?*Any behavioral health issues in the past?*Emotional or mental health issues or impact from traumatic experience.Current ConditionAny health issues this animal has presently.Current Health Issues*Physical illness or injuries. Any behavioral problems?*Emotional and mental health issues.Has your pet ever bitten anyone? Has it ever displayed any aggressive behavior?* Yes No If yes, please explain the aggressive behavior and consequences.Is your pet comfortable being touched all over its body?* Yes No If no, please explain where they are not comfortable being touched and the reactions to doing so.Name of Veterinarian and Practice For reference only. I will not contact your veterinarian unless you specifically ask me to.Current Veterinary DiagnosisCurrent Medications: Please list by name with start and end dates of each medication.Healing Session FocusPlease take the neccessary time to consider the following question.What needs do you and your animal have that you would like to be addressed during the healing session?*How did you hear about Earth Horse Healing?* After you press the submit button, please make sure you see a notice that the from was submitted. If it does not go through, the required field(s) that needs to be filled will be highlighted. Thank you!