New Client Intake Form — EquiZen PEMF

Email

Barn Name

Gate Code

Horse Name

Horse Age

Horse Breed

Horse Height

Horse Color

Sex

Injury History

Medications and Supplements

Diet (Hay, Grain, etc.)

Access to hay

Amount of daily turnout

Disipline

How often does the horse get ridden?

Any behavior problems in hand or under saddle? If yes, please explain.

Has the horse ever had a PEMF Session?

Are you planning to keep the horse on a maintenance schedule?

Reason for PEMF Session

Referred by:

Are you okay with pictures of your horse being used on EquiZen PEMF's website, marketing documents, and social media channels?

Client Policies

To be eligible for services from EquiZen PEMF, all new clients must adhere to this Client Policy. By scheduling an appointment with us after December 1, 2023, you agree to the following terms and conditions: MEDICAL HISTORY DISCLOSURE It is the client's responsibility to provide the following information about their horse when booking each session and to schedule the appointment accordingly: - Intramuscular (IM) injections, including vaccines, administered less than 24 hours before the session. - Intra-articular therapy (joint injections, such as IRAP, PRP, ProStride, stem cells, etc.) within 3 days before the session. - Shockwave therapy within 5 days before the session. - Pregnancy. - Blood clots, internal or external bleeding, or blood disorders. - Cancer or active infection. - Heart conditions. - Seizures, strokes, fainting, blood pressure disorders. - De-nerved limb(s) within the past 2 years. By signing this agreement, I understand that it is my responsibility as the owner, lessee, or agent of this horse to inform my practitioner of any of the above changes. I acknowledge that complications can arise despite best management practices and care, and EquiZen PEMF will not be held responsible for incomplete or inaccurate information provided by the owner or their proxy. A minor cannot act as a proxy or as an owner. CANCELLATIONS - If appointments are canceled less than 48 hours prior it will result in a $50 cancellation fee. - Alternatively, if the client can find a 'replacement' client/horse at the same location, cancellation fees will be waived. PAYMENT TERMS - Clients are financially responsible for all charges incurred for services rendered to the horse and must make payment at the time of services, unless other pre-arranged payment options have been agreed upon. Accepted payment methods include cash, check, and Venmo. - Late payments will incur a 3% fee per day for each day the invoice is overdue and not paid. - Prices are subject to change based on fluctuations in the cost of materials, supplies, or expenses. ADDITIONAL POLICIES - Horse should be in their stall or on the cross ties at the scheduled appointment time. - Someone must be present to handle any horse with dangerous habits on the ground during the session. - The horse should be clean and dry at the scheduled appointment time. - Please don’t schedule a session during the horses feeding time, if that is the case please make sure the horse is fed before the session is set to begin. - The right to terminate any session exists if the physical safety of the practitioner, horse, or horse owner/agent is deemed at risk. Reimbursement is at the practitioner's discretion. - EquiZen PEMF is not responsible for injuries, including severe and/or fatal injuries, to owners and/or approved agents handling their own horse during a visit. - The right to refuse service to anyone is reserved. By signing this agreement, I confirm that I am 18 years old or older, and I am the owner or approved agent (trainer/manager/lessee) of the horse receiving services from EquiZen PEMF. I have read and understood this document and agree to abide by the outlined policies.

Liability Wavier and Release Statement

With the acknowledgment of the potential risks of injury to myself, my horse, and/or property during the performance of MagnaWave pulsed electromagnetic field (PEMF) treatment, and in exchange for the PEMF treatment being administered, I, the undersigned, willingly and knowingly enter into this waiver and release of liability. This release encompasses myself, my heirs, executors, administrators, assigns, agents, or personal representatives, and I hereby relinquish any and all rights, claims, or causes of action of any nature that may arise from the PEMF treatment. I hereby grant a complete release and forever discharge EquiZen PEMF, inclusive of the company owner, Carly Nasznic, as well as all company officers, affiliates, staff, representatives, contractors, agents, and employees. Furthermore, I release and forever discharge MagnaWave, Inc and its affiliates, managers, members, agents, staff, heirs, representatives, predecessors, successors, and assigns, from any consequences of the PEMF treatment, including but not limited to illness, injury, death, damages, or economic loss that I or my horse may experience. I declare that I am at least 18 years old, and I have thoroughly read, comprehended, and agreed to this Liability Wavier and Release Statement. I recognize it as an informed release, and I am voluntarily and legally bound by its terms.