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Optimal Health Program
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Client Information:
Client Name: __________________________________ Spouse Name: ___________________________________
Address: ______________________________City: _______________State: ___________Zip Code: ____________
Home Phone : ___________________
Cell:______________________
Work: ___________________________
Email Address:_______________________ Would you like to receive our monthly newsletter?___________
Emergency Contact Name/Number:______________________________________________________________
Trainers Name:_____________________________ Trainers Phone Number/Address:______________________
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Patient Information:
Patient’s Registers Name :________________________________________ Barn Name:_____________________
Breed:_____________________ Age:____________ Color:____________________ Sex:______________________
Discipline/Use:___________________________________________________________________________________
What preventative Healthcare has he/she received in the past:_____________________________________
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When was your horse last vaccinated and which vaccinations were given?_________________________
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When was your horse last dewormed and what product was used?__________________________________
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When was your horse’s last dental exam and power float? _________________________________________
Any other history that you think we need to be aware of and have noted in the patient’s
file?_____________________________________________________________________________________________
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Allergic to any
vaccinations/medications?_______________________________________________________________________
What address is your horse currently located
at?_______________________________________________________________________________________________
1) Please circle desired program:
Performance Horse Program
Geriatric/Retired Horse Program
2) Please circle Deworming Program:
Daily Dewormer
Scheduled Paste (purge) Dewormer
3) Additional Options (please circle any add-ons you would like):
Performance Horse Add-ons:
Sheath Cleaning - $25.00
Health Certificates - $20.000
Geriatric/Retired Horse Add-ons:
Sheath Cleaning - $25.00
Payment Options:
Total Package: $________________ per year
Pay the entire amount up front and get the enrollment fee waived; and a discounted First Aid Kit.
Payment Option: Pay $_____________ at time of enrollment plus enrollment fee of 20.00 and
$__________________ within 6 months of enrollment date.
If this payment option is chosen, we require a credit/debit card to be kept on file.
Payment Method: Credit/Debit Card _________ Check __________ Cash ______________
Credit/Debit Card Number:______________________________________________ Exp Date:_______________
Security Code:____________ Cardholder Signature:_________________________________________________
Billing Address:________________________________________________________ Zip Code:_________________
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Signature
Date