Please fill out our Equine Pre-purchase Questionnaire below, if you would like us to perform a pre-purchase exam on your new potential equine partner.

Pre-Purchase Questionnaire

In Preparation for the Up-Coming Pre-Purchase Evaluation, Please Complete this Questionnaire

Purchaser

Purchaser First Name *

Purchaser Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address *

Phone *

Purchaser's Agent

Seller/Agent

Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone *

Current Trainer *

Currently Boarded At *

Patient

Name *

Age *

Gender *

Breed *

Color *

Brand *

Markings *

Intended Use *

History/Disclosure

History Provided by *

Length of Time with Current Owner *

Is the Horse Currently in Work *

Yes

Comments

Has the Horse Been Worked Today? (to be noted on day of appointment)

Vices

Deworming Date *

Dewormed with *

Vaccinations *

Date Of Vaccinations

Last Coggins Date *

FEI Passport *

Yes

Is the Horse Currently Insured *

Yes

Is the Horse on any Medications *

Yes

Comments

Have any Medications Been Given in the Last 48 Hours *

Yes

Comments

Medical History

Dental History

Surgical History

Musculoskeletal/Lameness History

Other Comments

Disclosure: I certify, to the best of my knowledge, that the above information is true and correct.

Signature Owner/Agent*

Date *

Spam Blocker

Pet Records Sign-in Appointment Requests Refill Requests Equine Emergencies Cat & Dog Emergencies

Happy Tails From Clients

It was my first visit for Chanel and I was deeply impressed with the details of the discussions. It is by far the cleanest veterinary clinic I have seen and I have been to many over the years in Indiana, Michigan and Florida. Cannot say enough about how the staff took to my pet. They connected immediately and won a friend.
- Jerry

New Patients Welcome

We are accepting new patients at Van Roekel & Associates! Our veterinary team is dedicated to the care of North Fort Myers dogs and cats, horses, and farm animals. Reach out today to book your animal's first appointment.

Equine Pre-Purchase Questionnaire

Pre-Purchase Questionnaire

Purchaser

Seller/Agent

Patient

History/Disclosure

New Patients Welcome