Equine Initial Appointment Form

MAIN PHONE NUMBER *

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SECONDARY PHONE NUMBER

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MAIN PHONE NUMBER *

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SECONDARY PHONE NUMBER

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DO YOU AGREE TO RECEIVE HORSE'S CONFIDENTIAL INFORMATION VIA EMAIL? *

Includes, summary reports, bloodwork, test results, etc.

YES

NO

CAN EITHER OWNER GIVE CONSENT? *

YES

NO

DO YOU CONSENT TO PHOTOGRAPHS OF YOUR HORSE TO BE USED FOR TEACHING OR RESEARCH PURPOSES? *

YES

NO

DO YOU CONSENT FOR YOUR HORSE'S CONSULTATION BEING AUDIO RECORDED FOR MEDICAL RECORD-KEEPING PURPOSE? *

Recordings are confidential and used only for clinical documentation and internal purposes

YES

NO

ARE THERE ANY OTHER ANIMALS AT THE BARN WHERE YOUR HORSE IS HOUSED? *

Select all that apply

CAT

DOG

GOAT/SHEEP

COW

CHICKEN

NONE

OTHER (please specify below)

DOES YOUR HORSE ITCH? *

YES

NO

WHEN?

CONSTANTLY

SPORADIC

NIGHT ONLY

DOES YOUR HORSE HAVE ANY RHINITIS, HEAVES OR NASAL DISCHARGE?

Select all the apply

RHINITIS

HEAVES

NASAL DISCHARGE

COUGH

WHAT TIME OF THE YEAR ARE THE SKIN/RESPIRATORY SIGNS WORSE? *

Select all the apply

SPRING

SUMMER

AUTUMN

WINTER

YEAR ROUND

DOES YOUR HORSE HAVE ANY SKIN LESIONS? *

YES

NO

ARE ANY OF THE OTHER HORSES AFFECTED AT THE BARN? *

YES

NO

ARE ANY HUMANS THE HOUSEHOLD/BARN AFFECTED? *

YES

NO

IS YOUR HORSE CURRENTLY TAKING ANY MEDICATIONS? *

YES

NO

IS YOUR PET CURRENTLY RECEIVING ANY SUPPLEMENTS? *

YES

NO

ARE YOU CURRENTLY DOING ANY TOPICAL THERAPIES *

I.E., SHAMPOOS, OINTMENTS

YES

NO

DO YOU USE FLY SPRAY ON YOUR HORSE? *

YES

NO