Pre-Purchase Exam

Download Fillable Pre-Purchase Exam Form

Purchaser Info
Contact Name*
First Last
Address
Street Address City State ZIP Code
Phone Number
Cell Number
Fax Number
Email*
Seller Info
Seller Name
First Last
Address
Street Address City State ZIP Code
Phone Number
Cell Number
Fax Number
Email
Trainer Info
Contact Name
First Last
Cell
Alternative #
Horse Info
Registered Name
Horse's Barn Name
Color
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Breed
Present Use
Intended Use
Purchaser, please check the boxes for each procedure you would like performed:
Exam
- Pre-Purchase Exam $362.00
Airway Evaluation
- In-Clinic Video Endoscopy $288.75
- Field Endoscopy $224.25
- Dynamic Endoscopy $341.00
Laboratory Testing
- Complete Blood Count $70.75
- Health Certificate (Additional charges for next day.)$21.75
- Chemistry Profile: In-House Lab STAT $149.00
- Chemistry Profile: Outside Lab $99.75
- Standard Coggins Test (5-7 days) $41.25
- 3 Day Express Coggins (Additional charges for next day. )$63.50
- Drug Screen $241.25 + Shipping
Digital Radiographs*
- Both Front Feet (12views) $510.50*
- Both Knees (10 views) $426.50*
- Both Hocks (8 views) $342.50*
- Both Stifles (6 views) $258.50*
- Both Front Fetlocks (8 views) $342.50*
- Both Hind Fetlocks (8 views) $342.50*
* A $35.75 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 $42.00.
Sports Medicine Ultrasound
- $261.50 Per Area of Concern (i.e. Left Front Suspensory Tendon)
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
Phone
Pre-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
Date Format: 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.
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Purchaser
Seller