Your Name * First Name Last Name Pet's Name * Email address * Contact number * (###) ### #### Postal address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pet's age or date of birth How long have you owned your horse? What breed is your horse? What gender is your horse? What colour is your horse? If your horse is insured, which company do you use? What is your horse's policy number (if applicable) What is the name of your regular vet clinic? * Has your horse received any other veterinary care? Please provide a brief description. What is the main concern about your horse? What age was the condition first noticed/how long has your horse had this issue? Have there every been any previous skin problems? Do you know of any relatives of this horse that have skin/respiratory issues? Is your horse stabled? If so please describe including bedding. Does your horse spend time with any other animals? If yes which species? Do you use routine insect control for your horse? If so what product and how often is it used? Is your horse rugged? If so what material are they made from? What material are saddle blankets, travel boots etc? What is your horses main use eg recreational riding, competing etc? Have any of the following symptoms been observed? Itching Sores Redness Dandruff Increased appetite Tiredness Weight loss Hives Scabs Diarrhoea Hair loss Odour Increased thirst Weight gain Cough Sneeze Runny nose/nasal discharge Runny eyes/ocular discharge Head shaking/head tossing Loss of appetite Increased urination Lameness Other How itchy is your horse on a scale of 0 - 10? Where did the issue start? Muzzle Eyes Ears Neck Mane Back Sides of chest Rump Tail Girth Abdomen/tummy Hind legs Front legs Bottom Groin Fetlocks Hooves Other Has it spread, if yes, to where? If the skin problems have been present for some time, which seasons are the symptoms worse? Are the symptoms present all year round? Yes No What, if anything, causes worsening of the symptoms? What helps the symptoms? List any medications used. Is your horse receiving any other medication(s)? Please list any vitamins or food supplements your horse is given. How often do you wash your horse and which shampoo do you use? What is your horse's current diet including treats? How long has your horse been fed this diet? Has your horse exhibited any behaviour changes, if so please provide details. Any additional comments? Do you consent to us posting images of your pet and using case information on our social media pages and website? * Please select one option Yes No Please acknowledge that we reserve the right to amend our prices when necessary. * Yes Please acknowledge that if you schedule an appointment but then fail to attend the confirmed appointment you will be charged a cancellation fee equvalent to the price of the consultation fee. The same fee applies to cancellations made less then 48 hours prior to the appointment. * Yes Thank you! Please complete this questionnaire prior to your initial consultation. New Client Form - Horse
