Sex: *

Mare

Gelding

Stud

Is the horse pregnant? *

YES

NO

Has this horse had any vaccinations in the last 72 hours?

YES

NO

Does this horse have active infection present?

YES

NO

Has this horse had a Neurectomy?

YES

NO

Has your veterinarian provided consent for Electro-Acuscope and Myopulse treatments? *

Yes

No

Veterinarian's Phone Number:

(###)

###

####

Owner's Information: *

First Name

Last Name

Phone:

(###)

###

####

How do you prefer to be contacted?

Check all that apply.

Phone

Text

Email