Equine Intake Profile Form
Thank you for your interest! We look forward to hearing more about your equine!
Owner Information
Owner First Name
Owner Last Name
Gender
Male
Female
Decline to Answer
E-mail
Phone
Mailing Street
Mailing City
Mailing State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Mailing Zip
Equine Information
Equine's Name
Equine's Location Street
Equine's Location City
Equine's Location State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Equine's Location Zip
How long have you owned equine?
Current Brand Inspection
Yes
No
Proof of Ownership
Yes
No
Registered
Yes
No
Equine's Registered Name
Species
Horse
Mule
Donkey
Breed
Sex
Gelding
Mare
Date Foaled
Height
Weight
Color and Markings or Scars
Past Job(s)
On a scale of 1-5, 1 being very calm and 5 being high spirited, how would you rate your equine?
Skills and Characteristics
Please check all that apply to your e
quine
.
Neck Rein
Direct Rein
Tie (at Rail)
Cross-Ties
Lunge
Load in Trailer
Stand for Farrier
Drive
Lead in Hand
Gaited
Canter Both Leads
Sound at All Gaits
Notes
Medical History
Please check all that your equine has a history of. Below please provide additional detail on each option selected.
Joint Injections
Periods of Lameness
Other Injuries
Colic
Allergies
Chronic Conditions
Medications/Supplements
N/A
Please indicate the date(s) and a detailed description for any options selected above.
Routine Veterinary and Farrier Records
Please list the most recent dates for the following:
Preferred Vet
Rabies
Vet Phone
Flu/Rhino
EWT/Encephalitis
West Nile
Neg. Coggins
Teeth Floated
Deworming
Product Used
Preferred Farrier
Farrier Frequency
Farrier Phone
Last Farrier Appt.
Farrier Service
Trim
Front Shoes Only
Front and Hind Shoes
Notes
In the Event of an Emergency, Hearts & Horses should Contact:
First Name
Last Name
Phone
Gender
Male
Female
Other
Other
Add Emergency Contact
First Name
Last Name
Phone
Gender
Male
Female
Other
Other
Other Information to Share About Your
Equine
Behavior in Herd
Riding Alone
Riding in a Group
Close to Other Equines
Ground Manners
Stable Vices
Cribbing/Wind Sucking/Weaving, etc.
Hay/Grain
Turnout/Pasture
Quirks
Aggressive Feed/Herd Behavior, Doesn't Like Traffic, Wind, Other Equines, Bucks, Kicks, etc.
Additional information you feel is important for us to know about your e
quine.
Is there a place to evaluate and ride the equine (with good footing) at its location?
Arena, Round Pen
Are you able to haul the equine to Hearts & Horses for the equine to be evaluated?
With a Health Certificate
Why do you want Hearts & Horses to consider your equine for our program?
Please upload recent photos (taken within the
past 30 days
) that you have of your equine to include: 1) Side view showing the equine's back (top line); 2) Front head shot; 3) Full body showing markings; 4) Any photos of your equine at their "job."
Would you like Hearts & Horses to consider your equine for:
Lease
Donation
Purchase
Contact Information