Broodmare Medical Exception Form

Exception Form for Broodmares who are not capable of breeding back to a Pennsylvania Stallion due to medical reasons. If you have any questions about this form please contact PHBA at 610-444-1050.

Broodmare Information

Broodmare Name(Required)

Broodmare Date of Birth(Required)

Broodmare Sire(Required)

Broodmare Dam(Required)

Tattoo or Microchip Number(Required)

Exception Details

PA Stallion Mare was to be bred(Required)

Upload Copy of the Stallion Contract(Required)

Max. file size: 256 MB.

Reason Mare cannot be bred back to a PA Stallion(Required)

Veterinarian Advised Medical Risk

Permanent Reproductive Condition

Deceased

Other

Is the condition permanent or temporary?(Required)

Permanent

Temporary

Unknown

Detailed medical explanation(Required)

Summarize diagnoses, relevant history, and why breeding back poses risk.

Veterinarian & Documentation

Veterinary Clinic Name

Attending Veterinarian(Required)

First Last

Veterinarian Email(Required)

Veterinarian Phone(Required)

Upload Veterinarian Letter (on letterhead, signed)(Required)

Max. file size: 256 MB.

Permission to contact veterinarian for verification(Required)

I authorize PHBA to contact my veterinarian regarding this submission.

Mare Owner Information

Broodmare Owner(Required)

Broodmare Owner Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Broodmare Owner Email Address(Required)

Broodmare Owner Phone(Required)

Certifications & Consent

Name of person filling out this form(Required)

First Last

Email(Required)

Phone(Required)

Phone

This field is for validation purposes and should be left unchanged.