(Please fill out and return with samples observing safe shipping practices. Please send payment with sample. You may pay by MasterCard or VISA by entering the appropriate numbers below. Circle appropriate responses.
Veterinarian: _____________________________Phone:_ ____________________________________
Fax: ____________________________________ E-mail:______________________
Clinic Address: _______________________________________________________________
Payment: Check for $38.00 or CC: MC Visa ______________________________ Exp. Date __/____
Horse: Name _______________________ Age ____ Breed _____ Sex ______Weight__________
Has this horse ever received treatment for EPM? Yes No Currently? Yes No
Please circle current medications: Oroquin-10 Decoquinate Levamisole Marquis Diclazuril
Is there any association between onset of signs and vaccination (60 days)? Yes No
How long has horse shown clinical signs consistent with EPM? _______________________
Is this considered a relapse? Yes No
Does the horse exhibit any cranial nerve signs? Yes No Depression? Yes No
Assign neurologic score, (0 being normal and 5 being recumbent): 0 1 2 3 4 5
{0 = normal, no deficit, 1= Deficit just detected at normal gait, 2= deficit easily detected, exacerbated by backing , turning, swaying, loin pressure, neck extension, 3= Deficit very prominent on walking, turning, loin pressure or neck extension, 4 = Stumbling, tripping and falling down spontaneously, 5= Recumbent, unable to rise}
ARE YOU WILLING TO TAKE REFERRAL CASES FOR THE DIAGNOSIS AND TREATMENT OF EPM IN YOUR AREA? Yes No
You would get a request through us that would include a name and phone number.
Please return this form with samples by 2 day express mail, FedEx, or UPS to:
Pathogenes, Inc. P.O. Box 970, Fairfield, FL 32634
15471 N. W. 112th Ave Reddick, Florida 32686
If you have any questions please call Dr. Ellison at 352-591-3221 or email us at sellison@pathogenes.com.
