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18930 Old Bayshore Rd North Fort Myers FL 33917 US
(239) 694-7177

Online Pharmacy
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Limited Time Offer
Enjoy a $25 First Exam – Book Now

Equine Pre-Purchase Questionnaire

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 *

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

Happy Tails From Clients

Excellent care received for our family dogs. Very knowledgeable and they really care about the patients they treat! Don’t be surprised if during your visit a goat or farm animal comes in! Pretty neat!
- Claire

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.