Pre-Purchase Seller Seller Name*Seller Phone Number*Buyer Name*Buyer Phone Number*Horse Name*Age*Sex*MaleFemaleBreed*Current use of horse*How long as the horse been in your care*Has this horse been in training in the last month?* Yes No How many days / week*Has this horse been in training in the last 3 days?* Yes No Today?* Yes No Medical HistoryHas the horse been examined or treated by a veterinarian in the last 6 months?* Yes No DVM name*Reason*Has the horse had any joint injections in the last 6 months?* Yes No Date* MM slash DD slash YYYY Joints*Previous X-rays or Ultrasound?* Yes No Date* MM slash DD slash YYYY Area(s)Previous injury, illness or colic?* Yes No Date* MM slash DD slash YYYY Reason*Has the horse ever exhibited neurological signs?* Yes No If yes, please explain*Has this horse had any exposure to infectious disease in the past 6 months?* Yes No If yes, please explain*Does this horse have any vices or shipping problems?* Yes No If yes, please explain*Has this horse been vaccinated or dewormed this year? Provide dates below.* Yes No West NileFlu/RhinoEWTOtherLast Deworming product & DateNegative Coggins (EIA) DateOther lab results in last 6 monthsDoes this horse receive any medication before or after competition?* Yes No List medications and reason*Has this horse received any medication in the last month?* Yes No List medications and reason*To the best of my knowledge the above statements are correct and I grant permission to conduct the examination as required, including any test(s) that the Veterinarian considers necessary. I also accept any risk to the horse during the course of the examination.* I agree Signature*NameThis field is for validation purposes and should be left unchanged.
