*Owner's Name

*Address

*City, State, Zip Code

*Phone

Alternative Phone

*Name

*Age

Mare, Gelding or Stallion

*Breed

First, tell us briefly what is going on with your horse:

General Questions:
When was your horse last dewormed and with what product?

Coggins Test

Rabies Vaccine

EWT

Flu/Rhino

West Nile Virus

Strangles

Dentistry

Was dentistry done by a veterinarian?

What feed does your horse eat and how much?

Any supplements?

What type of hay/pasture and how much per day?

Has your horse had any medical concerns in the past / any history of illness besides conditions we have treated him/her for? If so, please explain:

Do you or anyone else ride your horse?

If so, where? (on-site only, trail rides, shows, training events)

What discipline? (example barrel racing)

Does your horse live at your house, at a boarding facility, or off-site on the property you own/rent?

If your horse does not live at your mailing address, please list here the address of where the horse stays:

How long have you owned your horse?

Is this horse trained to allow basic veterinary handling? (ie picking up feet, haltering, leading, accepting injections).

*Primary Concern Today

Duration of symptoms

Getting better/worse?

*How is the horse feeling?

Appetite

For how long?

Drinking/Urination

For how long?

Any diarrhea?

Specify how many time/how many days

Any coughing or nasal discharge in the past two weeks?

Any lameness/soreness?

Has your horse had a similar problem in the past?

Please list all the medications you are currently giving your pet and how frequently you are giving them. Please list even if you were prescribed them by us as we want to confirm your pet is still receiving them. Please note if your pet has missed any doses within the past week and when it was missed. List the times you last gave each medication. (example: Furosemide 12.5 mg 1 tab once daily, last given at 8am today, one dose missed yesterday morning)

Is there anything else we need to know/any questions that you have?