Worm-Ed Programme Information & Registration Form

Email Address

example@example.com

Email address for billing (if different from above)

example@example.com

Name

First NameLast Name

Horse Owner/Agent for billing (if different from above)

First NameLast Name

Postal address for sending your starter pack

Street Address

Street Address Line 2

TownCity

Post Code

We are located at 32 Sanctuary Drive Glenbrook. If you would like to save on freight you have the option of collecting packs and dropping off samples to the letterbox.

What is the best number to contact you on?

AreaPhone Number

Does your property or the property your horse/s graze at, have an established or trying to establish a Dung Beetle population?

Do you require additional Pinworm test kits?

If so, how many?

ADULTS 2yrs + Details. Please supply as much information regarding product used and when as possible. It is important so we are able to advise the best time for FEC testing.

Rows	Horse Name	Age	Sex/Type	Breed	Name of last dewormer/drench given.	Date administered. If unknown please supply an approx. date
Horse 1
Horse 2
Horse 3
Horse 4
Horse 5
Horse 6
Horse 7
Horse 8
Horse 9
Horse 10
Horse 11
Horse 12
Horse 13
Horse 14
Horse 15

FOALS - Details. Please supply as much information as possible regarding product used and when. It is important so we are able to advise the best time for FEC testing.

Rows	Horse Name	DOB	Sex/Type	Breed	Name of last dewormer/drench given.	Date administered. If unknown please supply an approx. date
Foal 1
Foal 2
Foal 3
Foal 4
Foal 5

Have any of your horses been under the care of a veterinarian for possible worm or age related illness in the last six months? If yes, please briefly enter details below.

Please enter any veterinary care received or additional comments here:

Your General Practice vet will be informed of your horse/s joining Worm-Ed so that we can both provide a complete parasite management program. Please provide your clinic's name, a case veterinarian and an email address or phone number:

Do you give permission for your horses' results to be used anonymously for research purposes?

Thank you for completing our registration form. The office will be in touch regarding timing of your testing.

Worm-Ed is a subsidary of Blue Blood Equine Ltd.