SAMPLE FORMS – EQUINE

The attached documents are intended as samples which provide an equine veterinarian with forms that he/she may choose to consider or adapt as part of their practice. In addition to forms that apply to equine practice, documents with forms specific to companion animals, food producing animals and poultry are available as well as forms that may be used by all practices.

Sample Form Page

Equine Client Information Sheet 2

Equine Continuing Care Summary Sheet 3

Equine Medical Record 4-5

Equine Stable Visit Form 6

Herd Health Reproduction Record (Equine) 7

Herd Health Vaccination Record (Equine) 8

SAMPLE: EQUINE CLIENT INFORMATION Client ID #

Animal ID #

Client is owner or Client is authorized representative of owner

Multiple owners1

CLIENT INFORMATION:

Name:

Address 1:

Address 2: (lot, concession, township, stable/barn)

Phone: Home: Work: Cell: FAX:

Email Permission and Address:

Permission to transmit confidential information via email: Yes No

Address:

EMERGENCY CONTACT:

Name:

Address:

Phone: Home: Work: Cell: FAX:

Email:

Consent to act as client’s agent: Yes No

Authority for decision making: Financial: Up to $_______________

Medical Care:

Signature Client: Date:

Signature Veterinarian: Date:

1 Attach additional sheets as necessary for contact information of multiple owners.

SAMPLE: EQUINE CONTINUING CARE SUMMARY SHEET

Client ID: Animal ID:

Diagnosis:

Treatment / Tests:

Medications:

Exercise:

Withdrawal Times:

Dietary Directions:

Recheck Date:

Additional Instructions:

Veterinarian Signature: Date:

SAMPLE: EQUINE MEDICAL RECORD

Client ID: Animal ID:

Food Producing / Non Food Producing

Veterinarian: Date:

History / Previous Treatment Has another veterinarian been consulted? Yes Dr. __________________________ No

Presenting Complaint

Physical Examination

T: (F/C) HR: bpm RR: min.

Attitude: BCS:

Reproductive Status: Pregnant / Open / Fresh / Bred / Immature

Appetite: Normal / Partial / Absent Duration:

Signification Findings:

Equine Medical Record Client ID #

Animal ID #

Assessment:

Specimens Taken:

Instructions to Client: Product Amount Route Frequency Duration

Treatment Plan

Withdrawal Plan

________________________________________ Veterinarian Signature

____ / ____ / ____ Date:

SAMPLE: EQUINE STABLE VISIT RECORD

Veterinarian: ___________________________________________ Date: ___________________________________

Veterinary Facility: ___________________________________________________________________________________

Stable Address: _________________________________________ Trainer/Coach: ___________________________

Owner ID Animal ID Complaint Observations Assessment Procedure Treatment WD Comments

Notes:

SAMPLE: HERD HEALTH REPRODUCTION RECORD (EQUINE)

Year

Client ID #

Herd ID #

Veterinarian Signature: Date:

Date Herd ID # Services Date

Conceived Date Fresh

# Days Open

Remarks Initials

Total # of Services: Total # of Days Open:

Avg. # of Services / Conception: Avg. # of Days Open:

First Service Conception Rate:

SAMPLE: HERD HEALTH VACCINATION RECORD (EQUINE) (where no protocol exists)

Client ID: Animal/Herd ID:

Veterinarian: Date:

Disease to be vaccinated for: IBR, BVD, PI-3, BRSV / Leptospirosis

Age group to be vaccinated:

Vaccine Type:

Primary Dose:

Site of Administration:

Dosage and needle size:

Slaughter or milk withdrawal:

Disease to be vaccinated for: Neonatal Scours

Age group to be vaccinated:

Vaccine Type:

Primary Dose:

Site of Administration:

Dosage and needle size:

Slaughter or milk withdrawal:

Disease to be vaccinated for:

Age group to be vaccinated:

Vaccine Type:

Primary Dose:

Site of Administration:

Dosage and needle size:

Slaughter or milk withdrawal: