Rochester's Only Canine and Equine Rehabilitative Care Center
Providing Veterinary Rehab, Sports Medicine, Acupuncture and Chiropractic Services
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He is your friend, your partner, your defender, your dog. You are his life, his love, his leader. He will be yours, faithful and true, to the last beat of his heart. You owe it to him to be worthy of such devotion.
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TheraVet Acres New Equine Client Information Form
First Name
Middle Initial
Last Name
Address
City
State
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Connecticut
District of Columbia
Delaware
Florida
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Louisiana
Maine
Maryland
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New Hampshire
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Home Phone
Work Phone
Cell Phone
Barn Phone
E-mail
How Did You Hear About Us?
Registered Name
Horse's Stable Name
Breed
Birthdate
Sex
When did you obtain the horse?
Where was your horse obtained from?
Horse's Stable Address
Regular Veterinarian
Discipline
Do you compete?
How exercised
How often exercised
Turnout
Brand/Type of feed
How often fed
Supplements given (with amounts)
Medications (with amounts)
Allergies
Farrier
Date of last shod/trimmed
Shoes (select one)
Front
All Around
Barefoot
When were the teeth last floated/checked? By who?
Any vices? (Towards humans, kicking, biting, etc.)
Describe your horse's typical temperament
Any history of past injury, lameness or illness?
Current issue
Any recent x-rays, blood work, or other diagnostics performed for this condition?
Has the horse previously had a chiropractic adjustment?
How did he/she respond?
Has the horse previously had acupuncture?
How did he/she respond?
Please give us any other information that you feel could be beneficial to us in helping your horse:
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| Updated September 2011