Form Test Purchaser InfoContact Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Cell NumberFax NumberEmail* Seller InfoSeller Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Cell NumberFax NumberEmail* Trainer InfoContact Name First Last CellAlternative #Horse InfoRegistered Name* Horse's Barn Name Color* Date of Birth* MM slash DD slash YYYY Age* Markings* Gender*MareGeldingStallionBreed* Tattoo* Height (in hands)* Present Use* Intended Use Medical History*Purchaser, please check the boxes for each procedure you would like performed: Standard Pre-Purchase Exam, Extensive Pre-Purchase Exam Exam Standard Pre-Purchase Exam $232.00 Extensive Pre-Purchase Exam $325.00 Airway Evaluation In-Clinic Video Endoscopy $222.00 Field Endoscopy $203.75 Dynamic Endoscopy $224.75 Laboratory Testing Complete Blood Count $65.00 Health Certificate $19.50 Chemistry Profile: In-House Lab STAT $136.00 Chemistry Profile: Outside Lab $89.50 Standard Coggins Test (5-7 days) $34.00 Express Coggins (3 days )$54.25 Drug Screen $216.00 + Shipping Digital Radiographs* Both Front Feet (12views) $487.50 Both Knees (10 views) $412.50 Both Hocks (8 views) $337.50 Both Stifles (6 views) $262.50 Both Front Fetlocks (8 views) $337.50 Both Hind Fetlocks (8 views) $337.50 Sports Medicine Ultrasound $234.50 Per Area of Concern (i.e. Left Front Suspensory Tendon) * A $32.00 x-ray set-up fee applies if radiographs are requested. Additional charges many also apply if extra x-ray views are needed during the exam. Each additional x-ray is $37.50. Please describe any specific concerns you would like addressed in the Pre-Purchase Exam:If you will not be present at the exam, please list the name and telephone number of your representative below.Name First Last PhonePre-Purchase Examinations cannot be scheduled until Mid-Rivers Equine Centre has your credit card information and authorization; please call our office with that information (636.332.5373) or provide the information below. Please Note: Unanticipated services may incur additional cost.Terms Agreement* I understand that I am responsible for payment of the above procedures and treatments at the time of service. I authorize Mid-Rives Equine Centre to charge my invoice in its entirety to the credit card provided. Purchaser/Authorized Agent Date MM slash DD slash YYYY As the purchaser/authorized agent I authorize the Pre-Purchase Exam for the above mentioned horse. Check to authorize Credit Card Options Use current credit card on file. I will contact Mid-Rivers Equine Centre with credit card information.* * Please Note: Pre-Purchase Exams will be scheduled only after credit card information is received. Please contact the office at 636.332.5373 if we do not have a credit card on file.CAPTCHAPRE-PURCHASE EXAMPurchaser Name First Last Purchaser Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purchaser PhonePurchaser Email Seller Name First Last Seller Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Seller PhoneSeller Email Date Submitted Horse Name Color Gender Age Markings Breed Tattoo Height Use Medical HistoryEXAMINATION EYES Lids: _______________________________________ Corneas: ____________________________________ Scleras: _____________________________________ Iris/Lens: ____________________________________ Anterior Chamber(s): ___________________________ Vitereous/Retina: ______________________________ Optic Nerve(s): ________________________________ EARS Appearancea: __________________________________________________________________ Hearing: ____________________________________________________________________________ MOUTH Lips: __________________________________ Mocosal: _______________________________ Gingivae: ______________________________ Dentition: _______________________________ Bite: __________________________________ Arcades: ________________________________ Toungue: ______________________________ Wolf Teeth: ______________________________ Age Confirmationed: ____________________ Temperature (F): ________________________ Carnial Nerve Function: _________________________ LYMPH NODES Mandibular: __________________ Prescapular: _________________ Prefemoral: __________________ INTEGUMENT Tumors: ____________________________________________________________________________________________________________ Surgical Scars: ____________________________________________________________________________________________________________ Neurecotmry Sites: ____________________________________________________________________________________________________________ CARDIOVASCULAR SYSTEM Heart Rate Rest (BPM): ___________________ Heart Rate Post Exercise(BPM): ____________ Murmurs: _______________________________ Vein Patency Jugular: _____________________ Vein Patency Saphenous: __________________ CRT: _____________ EKG: ________________ RESPIRATORY SYSTEM Respiratory Rate Rest (BPM): _____________________________ Respiratory Rate Post Exercise (BPM): ______________________ Respiratory Rhythem: ____________________________________ Slap Test: _____________________________________________ UROGENITAL Hernia(s): _____________________________ Umbilicus: _____________________________ External Genitalia: ____________________ Palpation: ________________________________ Internal Genitalia: ____________________ CONFORMATION Overall Conformation: ____________________________________________________________________________________________________________ Muscle Symmetry: ____________________________________________________________________________________________________________ Neck & Trunk: ____________________________________________________________________________________________________________ Legs & Hoovers: ____________________________________________________________________________________________________________ LAMENESS EVALUATION Evaluation at trot in couter-clockwise direction: __________________________________________________________________________________________________________________________________________________________________ Evaluation at trot in clock-wise direction: __________________________________________________________________________________________________________________________________________________________________ LEFT FRONT LIMB Visual Evaluaiton: _________________________________________________________________________________________ Palpation: _________________________________________________________________________________________ Hoof Testers: _________________________________________________________________________________________ Flesion Test: _________________________________________________________________________________________ RIGHT FRONT LIMB Visual Evaluaiton: _________________________________________________________________________________________ Palpation: _________________________________________________________________________________________ Hoof Testers: _________________________________________________________________________________________ Flesion Test: _________________________________________________________________________________________ LEFT HING LIMB Visual Evaluaiton: _________________________________________________________________________________________ Palpation: _________________________________________________________________________________________ Hoof Testers: _________________________________________________________________________________________ Flesion Test: _________________________________________________________________________________________ RIGHT HIND LIMB Visual Evaluaiton: _________________________________________________________________________________________ Palpation: _________________________________________________________________________________________ Hoof Testers: _________________________________________________________________________________________ Flesion Test: _________________________________________________________________________________________ RADIOGRAPHS TAKEN Radiographs Taken: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Interpretation: ____________________________________________________________________________________________________________________________________________________________________ CBC: _________________________ Fibrinogent: ___________________________ Chemistry Profiesl: ____________________ Urinalysis: ____________________________ Fecal Exam: __________________________ Current Goggins: _______________________ Drug Scan Blood Drawn: _________________ Video Endoscopy: ______________________ Ultrasound Evaluation: ___________________ Overall Soundness Evaluations:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Observations Regarding General Personality________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Mid-Rivers Equine Centre Doctor:______________________________________________________________________________________________________ Date: __________