equine‐naturaltherapy Alice Zammit‐Maempel, Dip ICAT Equine by luckboy

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									VETERINARY REFERRAL FORM 

equine‐naturaltherapy  Alice Zammit‐Maempel, Dip ICAT.  Equine Sports Massage.  Shiatsu 
Mobile: 07985019170.  info@equine‐naturaltherapy.co.uk    Owner Details:    Name:    Address:    Post code:                                                                               Tel:  Horse’s Details:    Name:                                                                                      Breed:    Colour:                                                                                     Height:    D of B/Age:                                                                             Gender:    Weight:                                                                                   Vaccn date:                      I declare that I am the legal owner of the above named horse and that all the information given is  correct.  I consent to the horse receiving sports massage therapy/shiatsu.  I have read and agree  with the terms and conditions.      Signature:.......................................................................Date:................................................................    TO BE COMPLETED BY VETERINARY SURGEON.    Veterinary Surgeon:                                                                    Practice Stamp    Practice Address:      Tel:                                                                                                   Date:    Summary of any injuries, conditions, medications:          Comments:      I consent for the above named animal to receive sports massage therapy/shiatsu.      Signature:...........................................................................Date:.............................................................  Veterinary Surgeon     


								
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