Newton Baker Insurance Services, Inc.
1-800-334-7733  PO Box 247, Lakeview, NC 28350
VETERINARY CERTIFICATE OF EXAMINATION FOR MORTALITY, SURGICAL, MAJOR MEDICAL AND LOSS OF USE INSURANCE
OWNER PLEASE NOTE: We ask that you take the opportunity of this exam to review with your Veterinarian the need to update any shots or deworming. We also suggest that you discuss with your Veterinarian the intended health program of your horses for the next 12 months including a specific schedule for deworming.

Owner's Name________________________________________________________________________________________________________
 
Horses being examined for insurance should be moved about outside the stall to demonstrate soundness of limb and freedom of movement. Careful observation and inquiry should be made as to housing conditions and the presence of contagious disease The completed certificate should be forwarded to our office without delay.
I, ______________________________________________ do hereby certify that I am a graduate veterinarian holding a current license as such to practice in the State of ___________________________ State License# ___________________________ and that I have this day examined:
Horse:__________________________________________________________________________
ANY HORSE THAT HAS BEEN NERVED AT OR ABOVE THE FETLOCK AND ANY HORSE THAT HAS PREVIOUSLY SUFFERED FROM AN ATTACK OF COLIC MAY NOT BE INSURABLE.
  YES NO   YES NO
Pulse and respiration normal? _____ _____ Lameness or faulty conformation? _____ _____
Temperature normal? _____ _____ History or evidence of nerving? _____ _____
Eyes clinically normal? _____ _____ Has horse been castrated? When________? _____ _____
Heartbeat normal? _____ _____ If mare, is she reported in foal? Due date _____? _____ _____
History or evidence of bleeder? _____ _____ If male, are both testicles evident? _____ _____
History of colic? _____ _____ Evidence of vices or obiectionable habits? _____ _____
Evidence of laminitis? _____ _____ Date last fecal exam? ____________
How often dewormed and last date? ____________ Date last Tetanus shot? ____________
Has any type of surgery been performed on this animal, or is any type of surgery being contemplated7 If so, please give details.
Is there any likelihood of further complications or any need for followup surgical procedures as the result of any past surgery? ______ If so, please give the details.
Does the horse have any kind of congenital deformity or abnormality?________ If so, state if this abnormality or deformity could predispose the animal toward any need for surgical repair or correction.__________________________________________________________________
MARES ONLY: Has mare suffered any breeding or foaling complication or dystocia in the past? ____________________________________
Has she had any of the following: Please circle... Caesarian, Ovariectomy, Hysterectomy, Cervical Laceration Repair, Urethral Extension, Retained Placenta, Caslicks, Rectal Vaginal Fistula, Clitorectomy, Prolapsed Uterus? If so, please give details ________________________
Has official E.I.A. Test been run? _________ Date? _________ Lab. No. _________ Result ___________________________________________
EXCEPT AS NOTED, I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE HORSE IS SOUND.
Remarks _______________________________________________________________________________________________________
* IGG level for animals under 30 days old:____________________
Date & Time of Exam:_______________________ Signature of Veterinarian ________________________________ D.V.M.
Office Phone # (_______)____________________ Address ______________________________________________
VETERINARY CERTIFICATE SHOULD BE RECEIVED IN OUR OFFICE WITHIN 30 DAYS OF EXAM
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