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Surgery & Anesthesia
Radiology
Ultrasonography
Portable & Hospital Based Endoscopy
Laser Surgery
Pre-Purchase Exams
Shoeing Evaluations
Lameness Evaluation & Sports Medicine
Regenerative Therapies
Emergency & Intensive Care
Specialist Access
Facilities
Our Team
Colin Scruton
Miranda Noseck
Danielle Fritz
Aleta Schmah
Heather Egan
Glen
Testimonials
Contact Us
Procedure Consent Form
Surgery Consent Form
Euthanasia Consent Form
Pre-Purchase Consent Form
Pre-Purchase Questionnaire
Home
Our Services
Surgery & Anesthesia
Radiology
Ultrasonography
Portable & Hospital Based Endoscopy
Laser Surgery
Pre-Purchase Exams
Shoeing Evaluations
Lameness Evaluation & Sports Medicine
Regenerative Therapies
Emergency & Intensive Care
Specialist Access
Facilities
Our Team
Colin Scruton
Miranda Noseck
Danielle Fritz
Aleta Schmah
Heather Egan
Glen
Testimonials
Contact Us
Procedure Consent Form
Surgery Consent Form
Euthanasia Consent Form
Pre-Purchase Consent Form
Pre-Purchase Questionnaire
Menu
Hospital Location
990 Old Victoria Road, Nanaimo, BC V9R 6Z8
24-Hour Care
Emergency
250.468.5340
Pre-Purchase Questionnaire
Owner's Contact Information
First Name
Last Name
Phone
Email
Street Address
City
Province
Postal Code
Preferred Payment Method
Debit
Visa
Master Card
Cash
Cheque
e-Transfer
Patient's Contact Information
Animal's Name
D.O.B
Breed
Sex
Colour
Patient ID
How long has the horse been currently owned?
What has been the horse's previous use up to date?
Last Vaccines
Flu/Rhino
Yes
No
Unknown
Date
EWT (Eastern/Western Enceph plus Tetanus)
Yes
No
Unknown
Date
West Nile
Yes
No
Unknown
Date
Rabies
Yes
No
Unknown
Date
Strangles
Yes
No
Unknown
Date
Other
Last Wormed
Type of Worming
When shod/trimmed last and how often?
When were teeth floated last?
Current Diet
Current Medications Given
Oral Supplements Given
Are Veterinary records available?
Yes
No
Unknown
Have previous surgeries been performed?
Yes
No
Unknown
Date
Any previous episodes of colic?
Yes
No
Unknown
Date
Any previous history of lameness?
Yes
No
Unknown
Date
Any previous radiographs available?
Yes
No
Unknown
Date
Vices
History info provided by
Date
Comments (please explain any "yes" comments from above)
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