Gastric Scoping Clinic Application

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?

YesNo
Who is your primary veterinarian?
Horse Name
Age
Breed
Gender

MareGeldingStallion
Primary Discipline
Is your horse in active training?

YesNo
Housing

StallPastureStall & Turn Out
Does your horse receive grain?

YesNo
What type of grain is fed, and how frequent are feedings?
Does your horse receive any supplements?

YesNo
List all supplements
Type(s) of hay/roughage
Do you use gastric ulcer prevention?

YesNo
What preventative product(s) do you use?

UlcergardOther
How frequently are these products used?

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

MonthDayYear
Do you suspect your horse has gastric ulcers?

YesNo
Check all applicable indicators

Decreased performanceOff feedPoor coat qualityUnwilling to workPicky EaterWeight LossColicBad attitude/crabbyNot gaining weightCinchy/girthy
Describe prior colic episode(s)
Has your horse previously been diagnosed with gastric ulcers?

YesNo
When was the diagnosis made?
How was the diagnosis made?

GastroscopyPresumptive DiagnosisFecal Blood TestOther
Were these gastric ulcers treated?

YesNo
What product was used for treatment?

GastrogardOther
What was the start date of last treatment?

MonthDayYear
What was the duration of treatment?
I acknowledge that by accepting a complementary gastroscopy and sedation, valued at $335, I am committed to purchasing the recommended treatment of Gastrogard prescribed by a veterinarian should gastric ulcers be confirmed. Treatment could range from 7-30 days.
I acknowledge that should I be selected, I will attend the Equine Gastric Ulcer Syndrome Seminar hosted at Performance Equine Vets on May 24th at 6:30 PM.
Should be Empty: