Owner's Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Alternative PhoneHorse's Info: 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? When did your horse last receive each of the following vaccines/tests/treatments: 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). Yes No If no, please explain what he/she is not accustomed to:Primary Concern Today*Duration of symptoms Getting better/worse? How is the horse feeling?* Normal Slightly lethargic Very lethargic/weak Appetite* Normal Decreased Not eating at all For how long? Drinking/urination* Normal Decreased Increased For how long? Any diarrhea?* Yes No Specify how many time/how many days Any coughing or nasal discharge in the past two weeks?* Yes No If yes, please describeAny lameness/soreness?* Yes No If yes, please describeHas your horse had a similar problem in the past?* Yes No If yes, please give detailsPlease 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?EmailThis field is for validation purposes and should be left unchanged.
