Pre-Purchase/Lease Examination Information Form

Pre-Purchase/Lease Examination Information Form
Proposed Date of Examination*

MonthDayYear
Veterinarian Performing Examination*
Location of Examination*

Name of Barn

Street Address

CityState

Zip CodeCountry
Horse Information
Name*
Registered Name if Applicable
Breed*
Sex*
Age*
Color
Current Use
Discipline and level of work within the discipline.
Intended Use
Discipline and level of work within the discipline.
Buyer Information
Buyer Name*

First NameLast Name
Buyer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Buyer Phone Number:*
Email*
Buyer's Agent/Trainer Information

First NameLast Name
Buyer's Agent Phone Number
Buyer's Agent Email
Seller Information
Seller Name*

First NameLast Name
Seller Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Seller Phone Number*
Seller Email Address*
Seller's Agent/Trainer Information

First NameLast Name
Seller's Agent Phone Number
Seller's Agent Email
Pertinent/Recent History*
Additional Diagnostics Requested*

CBC/Chemistry PanelCogginsDrug ScreenDrug Screen with FirocoxibEPMLymeUltrasound Exam*RadiographsOther
*Radiograph Views
*Please specify if you would like standard (45 views) and/or list any specific views
Should be Empty: