Midwest Horse Welfare Foundation Inc. 

Please send to:
10990 State Hwy. 73
Pittsville, WI 54466

Spring 2010 Health Report Form
This form MUST be filled out and signed by a licensed vet and received in our office no later then June 15th, 2010. 
Failure to do so is grounds for removal of your adopted horse. Horses adopted in 2010 do not need a Health report 
filed until spring 2011. Please return this form along with a current photo of your adopted horse to the address above.
 A photo of the horse and a vet's signature, address, and phone number are mandatory with this form.

Date: ___________Name of adopted horse (horses name at the time of adoption) __________________

Adopter's Name: ____________________________ Phone number ___________________________

Adopter's Address: __________________________________________________________________

Veterinarian Name: __________________________ Phone number ___________________________

Veterinarian Address: ________________________________________________________________

Physical condition of horse______________________________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

Weight of horse __________________________________

Vaccinations given and when (4-way and West Nile are mandatory): ________________________________

Did you or your vet administer vaccinations? __________________________________________________

Wormers to be administered throughout the year (every 6 to 8 weeks): When? ________________________

Were teeth checked? ________________ Did they need floating? ________________________________

Date teeth were floated: ______________________

Hoof condition, regular trimmings: When? ____________________________________________________

Do you or your farrier trim your adopted horse's hooves? __________________________________________

Additional comments by adopter regarding horse's health: _________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________ 

Signature of Adopter: _______________________________________________ Date:_________________

Signature of Veterinarian: ___________________________________________ Date:_________________