Equine Recheck Form OWNER AND HORSE INFORMATION Last Name * First Name * Horse's Name * Additional Owner(s) Name(s) on File Address Line 1 * Address Line 2 City/Town * Province * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code * Phone Number * (###) ### #### HISTORY How Has Your Horse Been Since The Last Visit? * Current Itch Level (rate on a scale of 0-10) 0 = Not Itchy, 1-2 = Very Mild Itch, 3-4 = Mild Itch (more frequent), 5-6 = Moderate Itch (regular episodes), 7-8 = Severe Itch (prolonged), 9-10 = Extremely Itchy (continuous, unable to rest). Any Skin Lesions? * YES NO If Yes, Where Are The Lesions Located? Any Respiratory Issues? * YES NO If Yes, Please Provide Brief A Description Is Your Horse Receiving Immunotherapy (Allergy Serum)? * YES NO If Yes, List What Type (Oral or Injectable), How Much and How Often Please note if on Oral or Injectable Immunotherapy Is Your Horse Receiving Any Medication? * YES NO If Yes, Please List Current Medications Please list what medications your horse is receiving, how much and how often they are given Do You Use Fly Spray? * YES NO If Yes, List Which One DIET Current Feed * Current Treats Current Supplements ADDITIONAL INFORMATION Which Season Is Your Horse Most Affected? * Spring Summer Autumn Winter Year Round Are There Other Animals At The Barn Where Your Horse Is Housed? * Select all the apply Cat Dog Goat/Sheep Cow Chicken Other (please specify below) None Have Your Horse's Symptoms Improved Or Worsened? * Any Other Information You Feel Is Important For Us To Know? Do you have files (pictures or documents) to upload? * Yes No PLEASE NOTE: After you submit this form, you’ll be taken to a page where you can securely upload any recent photos or documents if you wish. Please have files ready and name them as follows: PetName_LastName_Date or PetName_LastName_FileType (Examples: Star_Smith_2025-08-09 or Tucker_Smith_Wellness Bloodwork) Thank you, we have received your recheck form. Next Step: If you have files to upload, please use our secure Dropbox link below. ⚠️Upload Guidelines:- Accepted formats: JPG/PNG or PDF- Maximum size: 5 MB per file (clear images around 1–2 MB are ideal)When uploading, use the following format: PET’S NAME + LAST NAME ON FILE + date OR PET NAME + LAST NAME ON FILE + FileType (Examples: Star_Smith_2025-08-09 or Star_Smith_Culture) ⚠️Files not named in this format may not be matched to your horse’s recordClick here to upload files
