2023 Wellness Program Sign Up

Thank you for your support of our wellness programs!

Please note this form allows a maximum of 5 horses to be enrolled. If you have more than 5 horses you would like to enroll, simply fill out another form until you have been able to include all of your horses. Thank you!

Are you a current client?(Required)

Name:(Required)

First Last

Phone:(Required)

This phone number is a:(Required)

Home phone

Cell phone

Work phone

Other

Secondary Phone Number:

Email:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Have we seen your horse before?(Required)

Your horse's name:(Required)

Your horse's DOB/age:(Required)

Breed:(Required)

Sex:(Required)

Horse's Boarding Location:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Trainer Name:

First Last

Trainer's phone number:

Trainer's email address:

Optimum Wellness Program $600

The following services are offered with this program for your horses. There are two visits included in the wellness program, one in the spring and one in the fall. Comprehensive Physical Exam - Spring & Fall A thorough exam of the following system is performed: ophthalmic, cardiovascular, respiratory, gastrointestinal, dermatological, and palpation of muscles & joints Body Weight & Nutrition Consultation - Spring & Fall Includes weight-taping Oral Examination & Teeth Floating - Spring or Fall Sheath cleaning is included for an additional charge Eastern & Western Encephalitis, Tetanus, West Nile Virus - Spring Rabies Vaccine - Spring or Fall Fecal Testing - June through October Testing for parasites Two Paste Dewormers - Spring & Fall The appropriate dewormer will be administered in the spring and fall 5% Discount on Additional Professional Services An additional 5% discount on all additional professional services outside of the wellness program services offered in 2023. No Trip Charge for Wellness Program Visits There is NO trip charge for the two included wellness program visits. However, any trips outside of the wellness program will be charged

Geriatric Wellness Program $950

In addition to all of the same services offered by the Optimum Wellness Program, we are pleased to offer the following testing for your older horses. Horses 16 years old and older have a 10% increased incidence of Cushing's and an 8% increase in blood abnormalities. Both of these percentages increase with age. ACTH/Insulin Blood Test Complete Blood Count & Blood Chemistry Test

I would like to enroll my horse into the following program:(Required)

Optimum Wellness Program - $600

Geriatric Wellness Program - $950

Elective Services:

Influenza/Rhinopneumonitis- Spring & Fall Dose $94

Coggins Test $52

Soundness Evaluation $223.13

Radiographic Evaluation of Front Feet $135

Farrier Consultation $113

I would not like any additional services.

In addition to the above options, we have revamped our wellness programs to be able to offer the best, individualized care for your horses. We made the following elective services available for you to choose from. These services are offered at a 15% discount. We recommend these services for horses who travel, perform, trail ride and are in other similar situations. These services must be selected at the time of enrollment and cannot be added on at a later date.

Do you have another horse you would like to enroll in the wellness program?(Required)

Yes

Have we seen your horse before?(Required)

Yes

Your Horse's Name:(Required)

DOB/age:(Required)

Breed:(Required)

Sex:(Required)

Horse's Boarding Location:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Trainer:

First Last

Trainer's Phone Number:

Trainer's email address:

I would like to enroll my horse in the following program:(Required)

Optimum Wellness Program - $600

Geriatric Wellness Program - $950

I would like to enroll my horse in the following elective services (offered at a 15% discount):

Influenza/Rhinopneumonitis - Spring & Fall Dose $94

Coggins Test - $52

Soundness Evaluation - $233.13

Radiographic Evaluation of Front Feet - $135

Farrier Consultation - $113

I would not like any additional services.

Do you have another horse you would like to enroll in the wellness program?(Required)

Yes

Have we seen your horse before?(Required)

Yes

Your horse's name:(Required)

DOB/age:(Required)

Breed:(Required)

Sex:(Required)

Horse's Boarding Location(Required)

Street Address Address Line 2 City State ZIP Code

Trainer:

First Last

Trainer's Phone Number:

Trainer's email address:

I would like to enroll my horse in the following program:(Required)

Optimum Wellness Program - $600

Geriatric Wellness Program- $950

I would like to enroll my horse in the following elective services (offered at a 15% discount):

Influenza/Rhinopneumonitis - Spring & Fall Dose $94

Coggins Test - $52

Soundness Evaluation - $233.13

Radiographic Evaluation of Front Feet - $135

Farrier Consultation - $113

I would not like any additional services.

Do you have another horse you would like to enroll in the wellness program?(Required)

Yes

Have we seen your horse before?(Required)

Yes

Your horse's name:(Required)

DOB/age:(Required)

Breed:(Required)

Sex:(Required)

Horse's Boarding Location:(Required)

Street Address Address Line 2 City State ZIP Code

Trainer:

First Last

Trainer's Phone Number:

Trainer's email address:

I would like to enroll my horse in the following program:(Required)

Optimum Wellness Program - $600

Geriatric Wellness Program - $950

I would like to enroll my horse in the following elective services (offered at a 15% discount):

Influenza/Rhinopneumonitis - Spring & Fall Dose $94

Coggins Test - $52

Soundness Evaluation - $233.13

Radiographic Evaluation of Front Feet - $135

Farrier Consultation - $113

I would not like any additional services.

Do you have another horse you would like to enroll in the wellness program?(Required)

Yes

Have we seen your horse before?(Required)

Yes

Your horse's name:(Required)

DOB/age:(Required)

Breed:(Required)

Sex(Required)

Horse's Boarding Location(Required)

Street Address Address Line 2 City State ZIP Code

Trainer:

First Last

Trainer's Phone Number:

Trainer's email address:

I would like to enroll my horse in the following program:(Required)

Optimum Wellness Program - $600

Geriatric Wellness Program - $950

I would like to enroll my horse in the following elective services (offered at a 15% discount):

Influenza/Rhinopneumonitis - Spring & Fall Dose $94

Coggins Test - $52

Soundness Evaluation - $233.13

Radiographic Evaluation of Front Feet - $135

Farrier Consultation - $113

I would not like any additional services.

Do you have another horse you would like to enroll in the wellness program?(Required)

Yes

Have we seen your horse before?(Required)

Yes

Your horse's name:(Required)

Your horse's DOB/age:(Required)

Breed:(Required)

Sex:(Required)

Horse's Boarding Location:(Required)

Street Address Address Line 2 City State ZIP Code

Trainer name:

First Last

Trainer's phone number:

Trainer's email address:

I would like to enroll my horse in the following wellness program:(Required)

Optimum Wellness Program - $600

Geriatric Wellness Program - $950

I would like to enroll my horse in the following elective services (offered at a 15% discount):

Influenza/Rhinopneumonitis - Spring & Fall Dose $94

Coggins Test $52

Soundness Evaluation $233.13

Radiographic Evaluation of Front feet $135

Farrier Consultation $113

I would not like any additional services.

I want to make:(Required)

A one time payment

Monthly Payments (includes an additional $2.95 monthly processing fee)

I agree to pay this by:(Required)

Authorizing Colorado Equine Clinic to charge the total amount to my credit card on file at the time of enrollment.

Calling Colorado Equine Clinic to charge the total amount to my credit card at the time of enrollment.

Paying the total amount by check at the time of enrollment.

I understand that the wellness programs are transferable but non-refundable. In the event that I no longer own the horse who was enrolled in the wellness program, I may transfer the remaining services to another horse that I own.(Required)

I agree

I understand that wellness visits are typically scheduled by region and I agree to work with Colorado Equine Clinic regarding my availability to be at these appointments. If I am not able to be at my horses wellness visit I authorize Colorado Equine Clinic to complete the wellness visit as scheduled without my presence. I understand that if my horse is turned out and I am not there to catch him I may be charged a separate catch fee not included in the wellness plan pricing. I understand that I may be given a 2-hour window rather than a specific time for my wellness visit.(Required)

I agree

I understand that this Wellness Program expires on December 31, 2023 and that my 5% discount on Professional Services is only applicable while my wellness plan is active for the year of 2023.(Required)

I agree

Today's Date:(Required)

Signature:(Required)

Comments

This field is for validation purposes and should be left unchanged.

2023 Wellness Program Sign Up

Thank you for your support of our wellness programs!

Optimum Wellness Program $600

Geriatric Wellness Program $950

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