Wanderlust Equine Bodywork LLC

Stacy McVey – Certified Equine

Massage Therapist

Client Intake Form

Date of Intake Horse Name

Owner Name Barn

Horse Information

Breed/Colour Age Sex

Discipline
Past History:

As owner or Authorized person responsible for the above described horse. I release
full bodywork care to Stacy McVey of Wanderlust Equine Bodywork LLC.

Date Signature

(719) 231-1874 wanderlustequinebodywork@gmail.com

 Wanderlust Equine Bodywork LLC

Stacy McVey – Certified Equine

Massage Therapist

Health History Intake Form:

Animal’s Name: _______________________ Weight: __________________
Diet:__________________________________________________________________________
Supplements: _________________________________________________________________
Appetite: __________________________ Coat Appearance: _____________________
Surgeries:______________________________________________________________________
X-rays:_________________________________________________________________________
Illness:__________________________________________________________________________
Injuries:_________________________________________________________________________
Orthopedic/Joint Issues:_________________________________________________________
Pain Management: _____________________________________________________________
Environmental Changes/Influences: ______________________________________________
_________________________________________________________________________________
Disposition Today: ________________________________________________________________
Guardian and Contact Information
The practitioner, Stacy McVey, reserves the rights to contact your veterinarian with any
questions about your animal(s).

Guardian Name: _________________________________________________________________

Address: _________________________________________________________________________
Phone: ____________________ Email: ____________________________________
Veterinarian Name and Number: __________________________________________________
Referred by: ____________________________ Years with current guardian: ___________
Previous Home: __________________________________________________________________
Guardian’s Goals and Objectives:
__________________________________________________________________________________

(719) 231-1874 wanderlustequinebodywork@gmail.com

 Wanderlust Equine Bodywork LLC

Stacy McVey – Certified Equine

Massage Therapist

Consent and Acknowledgment to Therapy

I have read and understand the below disclosure statement in regard to the therapy to be
given to my animal(s) ___________________________ by Stacy McVey and Wanderlust Equine
Bodywork LLC.
I understand that this person is not a veterinarian, that the therapy given is not to be
considered as veterinary treatment, and that the comments, suggestions, or
recommendations proffered in the course of this therapy are not to be construed as
veterinary medical advice. Massage/touch therapy and other holistic modalities are not a
substitute for veterinary medical care, but are rather a cooperative form of therapy.
I, _____________________________ (owner or agent of owner) wish to have this therapy for my
animal(s) and give my consent and acknowledgement by signing below, in compliance
with the Colorado Veterinary Practice Act.
I, _____________________________ (owner or agent of owner) certify that my animal has
received regular veterinary care and vaccinations, as needed.
In signing this document, I acknowledge that I have read and fully understand the previous
statements and consent to Stacy McVey and Wanderlust Equine Bodywork LLC performing
massage and/or acupressure on my animal. I understand that I am waiving any and all
claims that I may have against Stacy McVey and Wanderlust Equine Bodywork LLC.

Signed: _____________________________________________ Date: ________________

Witnessed: __________________________________________ Date: ________________
Statement of Disclosure
I am not a veterinarian; I do not diagnose medical issues, offer medical advice, prescribe
drugs, or perform surgery.
My role is that of a facilitator, assisting your animal(s) to attain and maintain a naturally
healthy state. The specific results of the bodywork sessions will be different for each animal:
beneficial effects of massage and bodywork include blood and lymph circulation,
endorphin release, increased trust and mood elevation, improved flexibility, body
awareness, muscle efficiency, increase in performance, shortened recovery time from illness,
injury, or surgery, emotional calming, and injury prevention.
Stacy McVey, Wanderlust Equine Bodywork LLC
(719) 231 – 1874

(719) 231-1874 wanderlustequinebodywork@gmail.com

 Wanderlust Equine Bodywork LLC

Stacy McVey – Certified Equine

Massage Therapist

Consent for Picture, Video, and Name Publishing

I, _________________________________ (owner or agent of the owner) hereby grant Stacy
McVey and Wanderlust Equine Bodywork LLC permission to take photographs and/or videos
of myself and/or my animal, and to publish those photographs or videos for any lawful
purpose , including, but not limited to, their website, social media accounts, and
promotional materials, either digital or in print, in perpetuity. I also grant permission to use my
name and/or my animal’s name.
By signing and dating this document, I authorize Stacy McVey and Wanderlust Equine
Bodywork LLC to edit, alter, share, remix, tweak, build upon or in any way alter the
photograph(s) or video(s) mentioned above. I also waive any rights of privacy or
compensation associated with the use of my or my animal’s image(s), video(s) for the
personal or commercial purposes outlined above.

Signed: ________________________________________ Date: _______________

Witnessed: _____________________________________ Date: _______________

Name to Appear in Published Material: __________________________________

Animal’s Name to Appear in Published Material: __________________________

Stacy McVey, ETMT, B.S. of Equine Science

Wanderlust Equine Bodywork LLC
(719) 231-1874
wanderlustequinebodywork@gmail.com

(719) 231-1874 wanderlustequinebodywork@gmail.com

 Wanderlust Equine Bodywork LLC

Stacy McVey – Certified Equine

Massage Therapist

First Examination
Horse’s Name: _________________________________________
Date and Time: ________________________________________
Breed: ____________________
Age: ____________
Gender: _______________________
Owner: __________________________________________________________
Session Price: _____________________________________________________
Next Appointment: _______________________
Visual Assessment: _______________________________________________________________
Massage Notes:

(719) 231-1874 wanderlustequinebodywork@gmail.com