Intake Form

Contact Information

Name*

First Last

Email Address*

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Horse Information

Horse Name

Breed

Age

Gender

Full instructions on how to take the measurements necessary for the body weight estimate can be downloaded here:
Body Weight Estimation Instructions (opens in a new window)

Weight

If growing estimated mature weight:

Girth Circumference in Inches:

Length in Inches:

Height in Inches:

Body Condition Scores

Full instructions on how to assess your horse's body condition can be downloaded here: Body Condition Scoring Instructions (opens in a new window)

Use the criteria on page 3 of the instructions to fill in the fields below.

Body Condition Score (NECK):

Neck

Body Condition Score (WITHERS):

Withers

Body Condition Score (SHOULDER):

Shoulder

Body Condition Score (RIBS):

Ribs

Body Condition Score (LOIN):

Loin

Body Condition Score (TAILHEAD):

Tailhead

Activity Level

Please use this area to describe a typical week’s work.

Would you say this work level is:

None

Light

Moderate

Heavy

Intense

If the horse is competing, in what discipline and at what level?

Reproduction Information

Pregnant

Yes

No

Stage of Gestation in Months:

Lactating

Yes

No

Stage of Lactation in Months:

Stallion

Yes

No

Currently Breeding?

Yes

No

Health History

Please describe in detail your horse's health issues.

Current Diet

Hay: Amount fed per day IN POUNDS not flakes:

Click '+' to add more hay types.

Type

AM

Lunch

PM

Total

Grain: Amount fed per day IN POUNDS not scoops:

Click '+' to add more grain types.

Brand/Type

AM

Lunch

PM

Total

Supplements: Amount fed per day In OUNCES or GRAMS not scoops:

Click '+' to add more supplements.

Brand/Type

AM

Lunch

PM

Total

Additional Information

Please review the following document with the requested remote consultation photographs: Requested Remote Consultation Photographs. Once you have taken these images of your horse, please send them to [email protected] as an attachment before your scheduled consultation.

Please use the following space to provide any further information you wish to share.

Please Note*

I understand that in order to receive an accurate diet assessment I must provide my horse’s current diet in pounds and ounces not scoops as well as the requested photographs of my horse.

How did you hear about us?

Who referred you?

If "Other" selected, please elaborate:

VERIFICATION: Please enter a number between 15 and thirty:*

Please enter a number from 15 to 30.

Phone

This field is for validation purposes and should be left unchanged.

Nutrition Consultations

Body Condition Scores

Activity Level

Reproduction Information

Current Diet

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