Equine Pre Purchase Exam Buyer Name*Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Horse InformationRegistered NameBarn NameBreedAgeSexColorAnticipated discipline/career/useLocation/Stabled atBilling InformationName of Credit Card Holder as listed on CardCheck oneVisaMCAmExDiscoverCareCreditCredit Card NumberSecurity CodeExp DateCredit Card Billing Address (if different from Prospective Buyers) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Signature giving authorization to charge card once pre-purchase exam is completeDate Date Format: MM slash DD slash YYYY Pre-Purchase exams start at $185. This includes our ambulatory fee, full physical exam, ophthalmic and dental exam. This also includes a lameness exam with standard flexions if tolerated by patient. If radiographs are requested they are $225 for a four view joint radiograph and additional joints are $85 each. We also provide an upper airway exam that is $225. If requested we can run a complete blood count and an equine profile for $115. Evaluation of radiographs taken will be performs within 5 days of exam with complete written report in 5 business days.Disclaimer:It is important to remember that the pre-purchase examination can only give the information about the horses’ health and condition on that day of the exam. While this information is very important, it is unfortunately never a complete picture. Many factors that impact the horse’s health are not necessarily detectable on the day of exam. The veterinarian cannot predict the horse’s future and no guarantee can be issued.The role of the veterinarian in the pre-purchase exam is not a “pass” or “fail” the horse. Instead it is to help you, the buyer, to make a more informed decision by providing information about the horses’ health. Ultimately the decision to purchase this animal can only be made by the prospective buyer.SignatureDate Date Format: MM slash DD slash YYYY Day of Exam: Scheduled Date Format: MM slash DD slash YYYY Who will present the horse at the ExamContact number for Buyer on Exam day if not presentPrepurchase Exam Options Complete Physical Exam and Flexion Tests, Hoof Tests Coggins Test Health Paper Needed X-rays**Additional testing may be added per discussion between the attending veterinarian and buyer at time of exam. Please select the basic scope of work desired at this exam:DestinationList JointsBloodwork Complete Blood Count/15 Point Blood Chemistry Thyroid Screen Any other testing, toxicology, etc. Airway Evaluation/Scopeat restafter workReproductive (Mare) Reproductive Ultrasound Uterine Culture BiopsyReproductive Stallion Breeding Soundness Evaluation **Scope of exam depends upon how the stallion is trained to collect.SignatureDate Date Format: MM slash DD slash YYYY