EmailMe Form - Spring Scoping Special Sign up

Owner Name *

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email

I am a current client of the following practice:

Windmiller Equine

Flying Horse Veterinary Practice

Other

Horse Name *

Breed

Age

Sex

Mare

Gelding

Stallion

Time preference for scoping on 3/28

AM

PM

Whenever

Please write your initials to indicate understanding of the following four statements:

I understand that I will be required to pay for the gastroscopy on the day of the event ($275) *

If my horse is diagnosed with gastric ulcers I will be given the option to purchase a 28 days supply of Gastrogard for $948 (for a total cost including scoping of $1223). Following this purchase, I will be given rebate coupons worth $196. *

I understand the initial discounted rate on Gastrogard of $948 will only be available on the day of the scoping and rebate coupons are only available for Gastrogard purchased through a veterinarian. *

I understand that fasting is required for gastroscopy and by initialing, show my intent to comply with all fasting requirements (which will be provided in a separate document). I also acknowledge that if I do not fast the horse as recommended, a gastroscopy may not be able to be performed. *