PRE PURCHASE EXAM SELLER FORM

Medical or Surgical treatments, health and soudness history of this animal

 

I hereby certify that the above statements are, to the best of my knowledge, true and complete responses to the items asked. I further certify that I am the owner, or duly authorized agent for the above described animal. I hereby grant my consent to the examination of the above named horse by De Cillo Equine Clinic for the purpose of determining the status of horse's health prior to sale.

PLEASE BE ADVISED THAT IT IS A REQUIRED SAFETY PROTOCOL AT DE CILLO EQUINE TO SEDATE ALL HORSES FOR ALL

DIAGNOSTIC IMAGING INCLUDING BUT NOT LIMITED TO RADIOGRAPHS AND ULTRASOUNDS. THE ATTENDING

VETERINARIAN WILL DECIDE THE TYPE AND AMOUNT OF SEDATION REQUIRED. DECILLO EQUINE CLINIC ADMINISTERS THE FOLLOWING SEDATIONS AS NEEDED; XYLAZINE, DORMOSEDAN, BUTORPHANOL, AND ACEPROMAZINE.

I UNDERSTAND THE SEDATION POLICY AND CONSENT TO SEDATION IF REQUIRED.

If you do not agree to the sedation policy, we cannot complete the Pre Purchase Exam at De Cillo Equine. I certify that, to the best of my knowledge, that this horse has not been/will not be treated with any oral, intraveneous, subcutaneous or intramuscular drugs within 10 days prior to the time of the PPE Examination.

Signature of seller or agent of seller. If this horse has been/will be medicated within 10 days prior to the PPE examination, please list the drug(s), amount, date,

I HEREBY AUTHORIZE THE RELEASE OF VETERINARIAN MEDICAL RECORDS TO DE CILLO EQUINE CLINIC AND TO THE

Signature of Co-Owner or agent (If applicable) Pre Purchase Exam Seller Form MAY 29 2025