Fill and Sign the Encephalomyelitis Sleeping Sickness Form

© 2017 - Cottonwood Equestrian Publications MARE INFORMATION SHEET To Be Kept By: ____________ (Fill out one for each mare to be bred) Owner's Name Phone No. (h) (as recorded with the Registry) (w) Address Street City State Zip Horses Name and Number Foaled Color Markings Anticipated arrival date Foal at Side? Sire of Foal Date/last foaling Does Horse have any dangerous propensities? If yes, describe: Stallion to which mare shall be bred: Medical History of Horse: Colic Frequency Founder When Allergies, if known Other Tetanus Toxoid Date VEE Encephalomyelitis (sleeping sickness), Eastern & Western Strains Date of last worming Coggins Test Feeding Program: Hay type Amount Grain type(s) Amount Pellets Amount Known allergies to feeds Special Care Requirements Habits To be contacted in case of emergency, if owner cannot be reached: Name Phone Number Address Is Horse insured? Insurance Carrier Policy # Carrier's Address Insurance contact for emergencies and phone number: Veterinary emergency contact: Name Phone Number This Horse is/is not considered a surgical candidate in the event of colic or serious illness (check © 2017 - Cottonwood Equestrian Publications one). _____IS _______IS NOT Owner's Initials_______