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.

YesNo

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?

YesNo

Do you require additional Pinworm test kits?

YesNo

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.

	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.

	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.

YesNo

Please enter any veterinary care received or additional comments here:

Would you be happy for your horses FEC to be shared with your GP vet if results indicate a reason too?*

YesNo

If yes, please provide your clinic's name, case veterinarian and an email address or phone number:*

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

YesNo

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.