2012 Equine Wellness Plan Enrollment Form
Please complete the following for each horse that you would like enrolled on a wellness
plan. Be sure to clearly indicate which options you would like for each horse.
 Horse’s Name____________________ Breed________________ DOB________
Sex: Gelding Mare Stallion Colour _________________ Weight_________ lbs.
Recreational Plan 
Comprehensive Plan 
I would also like this horse to receive a microchip  +/or an ID Card 
 Horse’s Name____________________ Breed________________ DOB________
Sex: Gelding Mare Stallion Colour _________________ Weight_________ lbs.
Recreational Plan 
Comprehensive Plan 
I would also like this horse to receive a microchip  +/or an ID Card 
 Horse’s Name____________________ Breed________________ DOB________
Sex: Gelding Mare Stallion Colour _________________ Weight_________ lbs.
Recreational Plan 
Comprehensive Plan 
I would also like this horse to receive a microchip  +/or an ID Card 
 Horse’s Name____________________ Breed________________ DOB________
Sex: Gelding Mare Stallion Colour _________________ Weight_________ lbs.
Recreational Plan 
Comprehensive Plan 
I would also like this horse to receive a microchip  +/or an ID Card 
I have enclosed a cheque for $_______________________
Please process $_______________________ to my Visa/ Mastercard.
Card Number _________________________________, expiry date___________
Card Holder’s Name ________________________________________________
Card Holder’s Signature _____________________________________________
Please return your completed form to us by fax 613-925-5900 or by mail to:
Rideau-St. Lawrence Veterinary Services
2725 Edward Street North
Prescott, Ontario K0E 1T0