Gastroscopy Admission Form – Piedmont Equine

If you have not already filled out a Veterinary Services Contract it must be done as well as the Pre-purchase Request Form- thank you!

PLEASE NOTE: For pricing details, please see our Pre-purchase Examination Pricing List.

PREPURCHASE EXAMINATION REQUEST FORM

PLEASE BRING TACK AND BE PREPARED TO RIDE

Owner:*
Horse*
Reason for gastroscopy?
Is this a repeat gastroscopy? If yes, have you noted an improvement in clinical signs?
Current medications (administration route, times, last time dose administered as well if they need additional dosage while hospitalized prior to gastroscopy).
Whom should we call following gastroscopy to discuss findings and treatment recommendations and to schedule a time to discharge the patient? Include best contact phone number please.
Any sedation concerns? (Previous sedation history, upcoming competitions)
Any additional diagnostics requested?
Any additional health concerns?