Submitted To: ____________________
(Fill out one for each horse)
Owner’s Name _______________________________ Phone No. (h): ______________
(as recorded with the Registry) (w) ______________
Address ________________________________________________________________
Street City State Zip
Horse’s Name __________________________________________________________
Registration Number _______________ Foaled ______________ Color ____________
Markings ____________________________ Anticipated Arrival Date _____________
Foal at Side? ________________________ Sire of Foal __________________________
Date/last foaling _____________________
Does Horse have any dangerous propensities? If yes, describe: ____________________
_______________________________________________________________________.
Stallion to which mare shall be bred: _________________________________________.
Medical History of Horse: Colic _______________ Frequency ____________________
Founder _______ When ___________________________________________________
Other: __________________________________________________________________
Allergies, if known ________________________________________________________
Tetanus Toxoid ____________________________________ Date __________________
Encephalomyelitis (sleeping sickness), East _____ West ____ Ven _____ WN _______
Flu __________, Rhino___________
(Not mandatory: Strangles _______, Rabies________, Potomac ________, EPM ______)
Date of last worming __________________________ Coggins Test ________________
Feeding Program: Hay type _______________________ Amount _______________
Grain type (s) _______________________ Amount _______________
Pellets ________________________ Amount ______________
Known allergies to feeds ___________________________________________________
Special Care Requirements _________________________________________________
Habits _________________________________________________________________
To be contacted in case of emergency, if owner cannot be reached:
______________________________________________________________________
Name Phone Number
_______________________________________________________________________
Address
Is Horse Insured? ______________
Insurance Carrier __________________________________ Policy # _______________
Carrier’s Address _________________________________________________________
Insurance contact for emergencies and phone number: ___________________________
_______________________________________________________________________
Veterinary emergency contact: ______________________________________________
Name __________________________ Phone Number __________________________
This Horse is/is not considered a surgical candidate in the event of colic or serious illness (check one). ___________ IS ______________ IS NOT
Owners Signature: _______________________________________________________
