In Preparation for the Up-Coming Pre-Purchase Evaluation, Please Complete this Questionnaire
Purchaser:
Name:
Phone: Cell:
Address:
Phone: Other:
Address:
City:
State/Province:
Purchaser's Agent:
Phone:
Seller/Agent:
Name:
Phone: Cell:
Address:
Phone: Other:
Address:
City:
State/Province:
Current Trainer:
Currently Boarded At:
Patient:
Name:
Age:
Gender:
Breed:
Color:
Brand:
Markings:
Intended Use:
History/Disclosure:
History Provided by:
Length of Time with Current Owner:
Is the Horse Currently in Work:
Yes
No
Comments:
Proposed Use of Horse:
Has the Horse Been Worked Today? (to be noted on day of appointment)
Vices:
Deworming: Date
With
Vaccinations:
Date:
Last Coggins: Date
FEI Passport:
Yes
No
Is the Horse Currently Insured:
Is the Horse on any Medications:
Yes
No
No
Yes
Comments:
Have any Medications Been Given in the Last 48 Hours:
No
Yes
Comments:
Medical History:
Dental History:
Surgical History:
Musculoskeletal/Lameness History:
Other Comments:
Disclosure: I certify, to the best of my knowledge, that the above information is true and correct.
Signature Owner/Agent:
Date:
SUBMIT