Wellness Program FormIf you want to print out the form CLICK HEREHorse Owner InformationApplicant's Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Is this a re-enrollment?* Yes NoHorse's InformationHorse's Name*Microchip*Please know that microchips can be scanned by the veterinarian.Boarding Location:The Terms and Conditions of the Bannon Woods Veterinary Hospital Wellness Program are specified below. To be eligible for the Colic Surgery Benefit in the wellness Program horses must have the following with a Bannon Woods Veterinarian. Horses must be microchipped to be eligible for enrollment. This permanent form of identification will be your horse’s enrollment number.Two Semiannual Visits, either in clinic or farm call with a Bannon Woods Veterinarian. Visits must be schedule 6 months apart with a 30 day overlap period in either direction to remain enrolled. Visit 1 must precede Visit 2 for participation in the Wellness Program. Vaccinations must be provided by and administered by a Bannon Woods Veterinarian. a. Visit 1: Comprehensive Physical ExaminationVaccinations required: Eastern and Western encephalitis, Tetanus, West NileFlu/Rhino EHV 1/4RabiesStranglesCoggins Test, Health CertificateOral Examination and dental floatFecal Test, Deworming b. Visit 2: Comprehensive Physical ExaminationVaccinations required: Flu/RhinoBotulismFecal Test, DewormingOral Examination and dental float if neededColic surgery must be performed at Bannon Woods Veterinary Hospital and performed by a Bannon Woods Veterinarian.Colic Benefit is effective 30 days after initial enrollment. Enrollment is done at the time of the first Comprehensive Examination.The semi-annual visit will be scheduled 6 months after visit 1. There is a 30-day grace period before and after the 6 month visit date to better accommodate our clients schedule. If the second visit is not preformed, then the horse is no longer eligible for wellness program benefits.Horses that are unable to receive the recommended vaccinations are not eligible for wellness benefits including the colic surgery benefit. Horses that are not eligible for the colic surgery benefit are still able to participate in the wellness program.Chiropractic Adjustment included with the Wellness package must be performed at one of the two wellness visits unless the horse is hauled into the clinic.Horses that undergo Colic Surgery at Bannon Woods Veterinary Hospital and take advantage of the Colic Surgery benefit agree to allow Bannon Woods Veterinary Hospital to share pictures of the patient on Social Media and other sources of advertisement. Personal information will not be released such as owner and patient name.All services must be performed on the same horse. No package splits. I hereby affirm that all the information in this Wellness Program Enrollment Application is factual and accurate. I agree to abide by all terms and conditions hereby stated in the Wellness Program Terms and Conditions.Attending DVM Signature:Date* MM slash DD slash YYYY Owner’s Signature:*Date* MM slash DD slash YYYY Comprehensive ExaminationOWNER NAME:*DR/T:Date* MM slash DD slash YYYY BARN/REGISTERED NAME:*M/C #:Age*Breed*Color*Sex* MARE GELDING STALLIONTEMPHRRR/CHARMMCRTDPBODY SCOREPREVIOUS HISTORYOWNER CONCERNSEYES WNL ABNORMALEARS WNL ABNORMALNOSE WNL ABNORMALHEART WNL ABNORMALRESPIRATION WNL ABNORMALGAIT WNL ABNORMALADDITIONAL FINDINGSDietDIET HAY GRAIN BOTHSUPPLEMENTS/FREQUENCY:GRAIN BRAND/QUANTITY/FREQUENCY:CURRENT MEDICATIONS/FREQUENCY:RECOMMENDED CHANGES:LifestyleDISCIPLINE(s):RIDING FREQUENCY/INTENSITY:STALLED:HRS PASTURE:HRS DRYLOT:HAY DURING TURNOUT: Yes NoRECOMMENDED CHANGES:ISSUES: Weight Loss Dropping Feed Abnormal Chewing Quidding Head Tossing Head tilt Colic Large Stem in Feces Hold Hard Leans to Ditch Lean to Line OtherPlease explain:CAPTCHAEmailThis field is for validation purposes and should be left unchanged.