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:
Format: (000) 000-0000.
Email
Buyer's Agent/Trainer Information

First NameLast Name
Buyer's Agent Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Seller Email Address
Seller's Agent/Trainer Information

First NameLast Name
Seller's Agent Phone Number
Format: (000) 000-0000.
Seller's Agent Email
Pertinent/Recent History
Additional Diagnostics Requested

Other
*Radiograph Views
*Please specify if you would like standard (45 views) and/or list any specific views
Should be Empty: