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Pre-Purchase Examination Seller Questionaire
Horse's Name
*
Seller's Name
*
First Name
Last Name
Seller's phone number
*
(###)
###
####
Seller's Email Address
Seller's Agent
Buyer's Name
*
First Name
Last Name
Horse's Year of Birth
Color
Breed
Gender
Gelding
Mare
Stallion
How long has seller owned this horse?
Current use of horse
Current veterinarian
Will medical record be released for review? (If yes, please email to ponymd@outlook.com prior to appointment)
Yes
No
Date of last negative Coggins test
MM
DD
YYYY
Date of last Rabies vaccine
MM
DD
YYYY
Date of last dental float
MM
DD
YYYY
History of colic surgery?
Yes
No
History of laminitis?
Yes
No
History of neurectomy ("nerving")?
Yes
No
History of "tie back"(throat) surgery?
Yes
No
Describe any history of lameness or medical issues:
Current diet: Hay and grain - amount and type
Daily supplements? Please list
Daily medications? Please list
By checking the following box, I, the seller of the horse indicated above, verify that the information above is, to the best of my knowledge, complete and correct.
*
Thank you!
