Gastric Scoping Clinic Application

Client Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

Are you a client of Performance Equine Vets?

Who is your primary veterinarian?

Horse Name

Age

Breed

Gender

Primary Discipline

Is your horse in active training?

Housing

Does your horse receive grain?

What type of grain is fed, and how frequent are feedings?

Does your horse receive any supplements?

List all supplements

Type(s) of hay/roughage

Do you use gastric ulcer prevention?

What preventative product(s) do you use?

Other

How frequently are these products used?

Other

What is the most recent date that you used a preventative product?

MonthDayYear

Do you suspect your horse has gastric ulcers?

Check all applicable indicators

Describe prior colic episode(s)

Has your horse previously been diagnosed with gastric ulcers?

When was the diagnosis made?

How was the diagnosis made?

Other

Were these gastric ulcers treated?

What product was used for treatment?

Other

What was the start date of last treatment?

MonthDayYear

What was the duration of treatment?