Veterinary Intake Form
To Be Completed By The Evaluating Veterinarian
Jockey Club Name
*
Jockey Club Number
Tattoo or Microchip
*
Year Born
Sex
*
Mare
Gelding
Color
*
Bay/Brown
Chestnut
Black
Grey/Roan
Other
Trainer
Owner
Barn
*
Stall Number
*
Medical History & Diagnosis
Radiographs
Yes
No
Notes
Ultrasound
Yes
No
Notes
Lameness Grade
*
BCS
*
Current Medications or Supplements
Copy of Coggins available
*
Yes
No
Veterinarian/Clinic
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date Examined
*
-
Month
-
Day
Year
Date
Signature
*
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