Newton Baker Insurance Services, Inc.

PO Box 247, LAKEVIEW, NC 28350
NATIONWIDE TOLL FREE 1-800-334-7733
FAX 1-800-874-3565
www.newtonbaker.com
We accept MasterCard, Visa, and American Express..

Horse Mortality Insurance

LOSS OF USE RENEWAL EXAMINATION

Name of Horse__________________________________ Age____ Breed________ Intended Use____________

GENERAL and CLINICAL EXAM:

Normal

Any Abnormal Findings

Body Conditions:

______

____________________

Eyes:

______

____________________

Palpation of Back:

______

____________________

Examination for Lameness at a walk and trot in a straight line and small circles in both directions on a hard surface:

______

____________________

Inspection of Stifles:

______

____________________

Fixation of the Patella: Left Not Possible____ Possible____

Fixation of the Patella: Right Not Possible____ Possible____

	Flexion Test		Palpation of Limbs Normal?		Response to Hoof Testers Normal?
	Neg.	Pos.	Yes	No	Yes	No
Left Forelimb	____	____	____	____	____	____
Right Forelimb	____	____	____	____	____	____
Left Hindlimb	____	____	____	____	____	____
Right Hindlimb	____	____	____	____	____	____
Comment on positive flexions or abnormal findings:

Is this animal currently receiving any performance-enhancing therapy or medications?

Are you aware of any injury, unsoundness or disease for which this horse has been treated in the past year?

Are you the regular attending vet?_______

Signature of Veterinarian______________________________________ Date of Exam____________________

Address____________________________________________________ Phone Number___________________

Professionally We Serve ~ Personally We Care

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