Exception Review Form

This form is for horses with colic surgery in the past year. Submit for case review.

Full Name

First Name *

Last Name *

Address

Email *

Phone Number

Contact information

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Veterinarian Name:

Vet Name

Veterinarian Clinic:

Vet Clinic

Veterinarian Phone:

Vet Phone

Horse Information

Horse Name:

Horse Name

Breed:

Breed

Age (in years):

Age

Gender:

Male
Female
Gelding

Microchip or Registration Number (optional):

Microchip

Date of Last Veterinary Exam:

Date

Has the horse received annual wellness care?

Colic History

Date of Last Colic Surgery:

Date

Details of Colic Episode:

Details of Colic Episode

Veterinary Report (PDF/JPG, max 10MB):

Attachments

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-122003-file2-2_

Has the horse been on any gut health supplements in the past year?

Purchase and Protocol Confirmation

Equiflavin Purchase Date:

Purchase Date *

Shopify Order ID *

Proof of Purchase (PDF/JPG, max 5MB):

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-122003-file2-1_

Bottle Size (in ml) *

1 Bottle (20 Servings) — (60 ml)
1/4 LITER (Approx. 84 Servings)
Option 3/2 LITER (Approx. 167 Servings)
Option 41 LITER (Approx. 334 Servings)

Quantity *

Purchase Type *

One-Time Purchase
Monthly Subscription
Quarterly Subscription

Subscription Active?

Consent

I certify that I will administer two 5ml doses of Equiflavin weekly and at least 10ml during any colic episode.
I confirm the horse has no history of colic surgery in the past 365 days.

Additional Notes:

Additional Notes

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Country/Region

Country/Region

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