Seller's Disclosure for Prepurchase Exam

Pre-Purchase Exam Seller's Disclosure

Pacific Crest Equine Veterinary Services
Current Owner/Seller

First NameLast Name
Seller's Agent if Applicable

First NameLast Name
Current Owner or Agent's Email
example@example.com
Current Owner or Agent's Phone
Please enter a valid phone number.
Name of Buyer

First NameLast Name
Horse Basic Info

Name (Registered & Barn Names)BreedColorHeightAge
Other Horse Info

Registration NumberAre registration papers available?
How long have you/the seller owned this horse?
What is the horse currently being used for? What is the current training intensity/frequency?
Medical History

For any answers requiring further explanation, please provide a written explanation at the end of this section.
Date of Most Recent Vaccinations
Tetanus:   Date    West Nile   Date
Eastern & Western Equine Encephalitis (EEE/WEE):   Date
Rabies:   Date   Influenza:   Date   Rhino:   Date
Other Vaccinations?
How often has the patient been dewormed in the last 12 months? What was the last dewormer used?
Date of last Dental

MonthDayYear
Date
Is the patient eating normally?

YesNo
Is the patient coughing?

YesNo
Does the patient have diarrhea or abnormal stool ?

YesNo
Does the patient scratch or itch?

YesNo
Does the patient have any vices?

YesNo
Has the patient been depressed or listless?

YesNo
Does the patient drink excessive amounts of water or urinate excessively?

YesNo
Has the patient ever colicked?

YesNo
Has the patient ever been lame?

YesNo
If yes please explain any previous or current lameness
Does the patient currently have or have they ever needed corrective shoeing? If yes, please explain.
How often does the patient trip or stumble?

Very rarely/neverOccasionallyFrequently
Has the patient had a Coggins test within the last 12 months?

YesNo
Date of most recent negative Coggins test

MonthDayYear
Date
Has the patient had any offspring?

YesNo
If the patient has had offspring, how many have they had and when was the most recent one?
Is the patient currently pregnant or being used as a breeding stallion?

YesNo
Please provide any further information on any known medical or lameness issues.
Any surgical procedures performed on this patient (other than castration)?

YesNo
If the patient has had a surgical procedure: what was the procedure and when? Any complications?
Are any drugs currently used for any purpose in this patient?

YesNo
Please list any drugs currently used and the frequency of administration.
Has this patient had any other serious injuries or illnesses? If yes, please explain.
What is the patient's current diet?
Name of Current Veterinarian

First NameLast Name
May we contact the current veterinarian for health records?

YesNo
The above information and medical history is true to the best of my knowledge. Signature of seller or seller's agent:

Powered by Jotform SignClear
Should be Empty:

Pre-Purchase Exam Seller's Disclosure

Medical History