VIRGINIA EQUINE PLLC
Douglas K. Daniels, DVM
Heather D. Caplan, DVM
Lindsay A. Neist, DVM
Western Riders Vaccination Clinic
February 12, 2012
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Client Information
______________________________________ ___________________________ Client Name Home Telephone
__________________________________________________________________ _______________________________________________ Client Address Cell Phone
__________________________________________________________________ _______________________________________________ City, State, Zip Email Address
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Patient Information
_________________________________ _____________________________ Registered Name Nickname
______________________________________________________ _____________________ _____________________ Breed Age/Birthdate Color
_Gelding Mare Stallion ________________________ _______________________________________________ Circle One Tattoo/Brand
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Selections .
Combinations __Individually
EWT, FLU, RHINO, & WNV….$56 ___________ Rabies…….....$12 _________
PHF & RABIES………………...$30 ___________ WNV …….....$25 _________
COGGINS………………………$30 ___________ Strangles……$24 __________
(pre-order only)
Chiropractic Evaluation ………...$35 ___________ Chiropractic Treatment $85 ______
(will credit towards Treatment if performed)
Total $__________ Cash only
Western Riders is a Virginia Quarter Horse Association Open Show Program participant. If you are a member of the Virginia Quarter Horse Association and show your registered Quarter Horse at a Western Riders show, you may earn points and be eligible for year-end awards from the VQHA. Exhibitors should submit a "Year End and Merit Award Eligibility and Point Reporting Form" in accordance with the rules of the VQHA Open Show Awards Program. Our Show Secretary will have this form available at the WRV announcer's booth. It is your responsibility to make sure this form is completed before you leave the show grounds. A separate copy of this form must be used for each show. Complete VQHA Open Show Program rules and Point Reporting forms are available at www.vaquarterhorse.com.
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