Seller Disclosure Form - Rogue Equine & Companion Animal Clinic

Legal owner as of this date*

First Last

Owner Physical Address*

Street Address Address Line 2 City State ZIP Code

Owner Mailing Address (if different, otherwise leave blank)

Street Address Address Line 2 City State ZIP Code

Owner Mobile Phone Number*

Owner Email Address

Legal Representative of Owner (if present)

First Last

Person representing owner, whether owner is present or not. Mark n/a if not applicable.

Legal Representative's Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please complete this portion if a Legal Representative of the owner is present.

Legal Representative's Mobile Phone Number

Please complete this portion if a Legal Representative of the owner is present.

Registered name of horse (mark n/a if unknown)*

Barn or common name of horse (mark n/a if unknown)*

Breed*

Sex (please choose one)*

Color and markings*

Please note breed recognized color and significant markings, such as star, white pastern, etc. Please note any brands.

Date of birth of the horse*

Period of ownership of this horse? Years, months or days please.*

I will be present at the exam.*

Yes
No

Prospective Buyer's Name?*

Current Location of Stabling*

Please note if at home or boarding facility.

Current Feeding Program*

Please note forage (grass, alfalfa or both), concentrates and or green grass pasture.

Current Stabling Enviornment*

Stall, stall with paddock, paddock only, dry lot, or pasture or mix of which?

Trim/shoeing frequency in weeks?*

Date of last trim/shoeing*

Deworming Frequency in weeks or months*

List last dewormer used*

Date of last deworming*

Vaccination List*

Tetanus
Eastern and Western Encephalitis
Influenza and Rhinopneumonitis
Potomac Horse Fever
Rabies
Strangles
Other
Unknown
None

Please tick the box for each disease the horse is vaccinated. Tick the box for "Other" if the vaccine is not listed. Only list those given within the last 12 months.

Date of Last Vaccination

Please leave blank if not known if never done.

Date of Last Dentistry

Please leave blank if not known or never done.

Section Break

Does the horse have any vices or unusual behaviors? Please note no or yes. If yes, please describe.*

Does the horse load and trailer?*

Is the horse on any medication? If yes, please list and explain.

Has the horse had any medication in the last 30 days?*

Has the horse ever been examined for lameness or any orthopedic problem? If yes, please explain.*

Has the horse ever had X-rays taken?*

Has the horse ever had any neurological problems?*

Has the horse ever had any episodes of colic?*

Has the horse had any respiratory disease?*

Has the horse ever had surgery?*

If mare or stallion, has the horse ever been bred?*

Has the horse ever been seen by any veterinarian at Rogue Equine?*

Yes
No

If yes, please note for what reason and approximately when.

Buyer/Agent subject to cancellation fee*

I acknowledge

The buyer/agent - typically the entity responsible for the financial obligation of a Purchase Examination - may incur a cancellation fee if the confirmed standing appointment is cancelled within 24 hours.

Comments or Concerns

Please note here any comments or concerns you would like to state or have addressed before, at or following the examination.

Agree, consent and authorize.*

I agree, consent and authorize

I, the undersigned, certify that I am the owner, or duly authorized agent of the owner, of listed above equine. To the best of my knowledge, the answers to the above questions are true and correct. Rogue Equine Hospital has my permission to share the information placed on this form with the prospective Buyer/Agent named above. In addition, I hereby grant my consent to allow the examination procedures to be performed by Rogue Equine Hospital for the purpose of determining the health status of the equine listed above for sale.

Signature of OWNER*

Signature of LEGAL REPRESENTATIVE

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