Equine Preadmission Certificate

This certificate must be completed by a veterinarian.

Owner: *

Name of the stable:

Horse name: *

VACCINATION

Important: all elective (non-emergency) appointments require a booster vaccination (or primary vaccination) against Influenza and Herpesvirus that is less than 6 months old (and more than 7 days old).

FOR ELECTIVE APPOINTMENTS:

1. Influenza - Vaccine name:

1. Date of last vaccination

2. Herpesvirus 1.4 - Vaccine name:

2. Date of last vaccination

OTHER INFECTIOUS DISEASES
(For medical record)

3. West Nile Virus - Vaccine name:

3. Date of last vaccination

4. Eastern and western equine encephalitis - Vaccine name:

4. Date of last vaccination

5. Tetanus - Vaccine name:

5. Date of last vaccination

6. Rabies - Vaccine name:

6. Date of last vaccination

7. Strangles - Vaccine name:

7. Date of last vaccination

8. Botulinum - Vaccine name:

8. Date of last vaccination

9. Potomac horse fever - Vaccine name:

9. Date of last vaccination

GENERAL HISTORY (BIOSECURITY)

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

Yes
No
Unknown

If yes, date of the last signs:

the weeks? Date

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

Yes
No
Unknown

If yes, date of the last signs:

I confirm that the information is correct.

Your name (veterinarian): *

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

Other relevant informations:

Signature

Clear Signature