Midwest Horse Welfare Foundation Inc. 

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

Spring 2012 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, 2011. 
Failure to do so is grounds for removal of your adopted horse.  Please return this form along with a current photo of your adopted horse to the address above.
 A current photo of the horse and a vet's signature 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: Overweight ______  Normal Weight  ______  Slightly thin ______ Very Thin _______

What vaccinations were given and when (4-way and West Nile are mandatory): ______________________

Did you administer vaccinations or did you give them? ________________________________________

Wormers administered throughout the year (every 6 to 8 weeks): Dates: _________________________

If  you do not follow the worming program above, you MUST send proof of fecal egg counts.

Date teeth were checked? ________________ Did they need floating? ___________________________

Date teeth were floated: ______________________

Hoof condition, regular trimmings: Trim dates: ________________________________________________

Do you trim your adopted horse's hooves or does your farrier do it ? ______________________

Additional comments by adopter regarding horse's health: ____________________________________

_________________________________________________________________________________

Signature of Adopter: _______________________________________________ Date:____________

Signature of Veterinarian: ___________________________________________ Date:____________