Equine Preadmission Certificate

(*) Required fields.

Owner: *

Name of the stable:

Horse name : *

VACCINATION HISTORY

Influenza : this horse is vaccinated against influenza (primary vaccination and
booster in the last 6 months, at least one week before admission). For the moment, elective unvaccinated cases are not admitted.*
YesNoUnknown

Name of vaccine if known, and date of last vaccine booster :

Herpes virus : this horse is vaccinated against herpes (EHV) (primary vaccination
and booster in the last 6 months, at least one week before admission).*
YesNoUnknown

Name of vaccine if known, and date of last vaccine booster :

GENERAL HISTORY (BIOSECURITY)

Has the horse shown any cough, fever, nasal discharge or diarrhea in the past 2 weeks?*
YesNoUnknown

If yes, date of the last signs:

Have the horses in the stable shown any signs of respiratory illness, fever or diarrhea during the past 2 weeks?*
YesNoUnknown

If yes, date of the last signs:

I confirm that the information is correct.*
Yes

Your name (veterinarian): *

Your email (a copy of this certificate will be sent to you):*