Buyer Information

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Secondary Phone

Email *

Veterinarian *

Intended use of this horse: *

Seller Information

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Secondary Phone

Email *

Veterinarian *

Past / current use of this horse: *

Horse Information

Registered Name *

Barn Name *

Age *

Gender

Stud
Gelding
Mare

Height *

Weight *

Breed *

Color *

Tattoo / Brand *

Markings *

Currently boarded at: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

History / Disclosures

History provided by: *

Length of time with current owner: *

Location of veterinary records: *

Is the horse currently in work? *

Yes
No

Performance history (level & date of last competition) – if applicable:

Proposed use of horse:

Vices (ie. cribbing, wind sucking, weaving, biting, etc):

Last deworming date: *

Last dewormed with:

When was this horse last vaccinated? And which vaccines were given? *

Has this horse ever had a vaccine reaction? *

Yes
No

Please explain.

When was this horse last shod/trimmed? *

Where is this horse kept? (ie. Pasture, dry lot, stable, etc) *

Has this horse ever been tied up? *

Yes
No

Has this horse ever been bred?

Yes
No

Date of last Coggins? Please provide result. *

FEI passport?

Yes
No

Is this horse currently insured?

Yes
No

Is this horse on any medications? *

Yes
No

Please specify the medication(s).

Medical history (please describe veterinary examinations/treatments/medications in the last 12 months): *

Dental history/date of last dental: *

Surgical history: *

Has this horse had x-rays taken?* *

Musculoskeletal/lameness history: *

Has this horse ever had joint injections? If so, when and which joints? *

Disclosure: The above statements are true and complete to the best of my knowledge. I, the undersigned, certify that I am the owner of the above described animal. I hereby grant my consent to allow the examination procedures to be performed by an associate of Central Veterinary Services for the purpose of determining the health status of the horse listed above prior to sale. *

I have read and understand.

Owner/Agent Signature *

Today's Date *

Pre-Purchase Questionnaire –
Seller History

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Buyer Information

Seller Information

Horse Information

History / Disclosures

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Pre-Purchase Questionnaire – Seller History

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Buyer Information

Seller Information

Horse Information

History / Disclosures

Pre-Purchase Questionnaire –
Seller History