REFERENCE NO:

Name:

Address:

Address of Yard if different to above. Please specify postcode:

Telephone: (best number to reach you on):

Email:

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Please √ which of the following options you are applying for:

 Other:

Name, type and size of your horse

Briefly describe the problem you are having with your horse.

Does your horse have any medical problems or has it in last 3 months suffered from strangles or other infectious disease? 

YES/NO

If yes, please detail below

Has your horse's back been checked by a Vet or suitably qualified person?  If yes, please give details.

Have your horse’s teeth been checked by an equine dentist or suitably qualified person? If yes please state when. 

Please supply details of vaccination and worming dates and Passport number

Vaccination

What outcomes would you like to achieve by working with Paddy?

1.

2.

Where did you hear about Horseshrink?

Are you a member of Intelligent Horsemanship?

 Yes/No:

IH Number:

Declaration:

I confirm that all information provided in the form is correct to the best of my knowledge and that I have read and agree to abide by the terms and conditions set by Horseshrink/ Equine Therapy Centre.

I confirm that my horse has appropriate and current third party liability insurance cover.

Signature:

Date: