Pre-Purchase Exam Download Fillable Pre-Purchase Exam Form Purchaser InfoContact Name* First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberCell NumberFax NumberEmail* Seller InfoSeller Name First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberCell NumberFax NumberEmail Trainer InfoContact Name First Last CellAlternative #Horse InfoRegistered NameHorse's Barn NameColorDate of Birth MM slash DD slash YYYY GenderMareGeldingStallionBreedPresent UseIntended UsePurchaser, please check the boxes for each procedure you would like performed: Exam Pre-Purchase Exam $432.50 Airway Evaluation In-Clinic Video Endoscopy $334.00 Limited Field Endoscopy $Call For Pricing Dynamic Endoscopy $393.00 Laboratory Testing Complete Blood Count $85.75 Health Certificate (Additional charges for next day.) $27.50 Chemistry Profile: In-House Lab STAT $242.75 Chemistry Profile: Outside Lab $120.75 Standard Coggins Test (5-7 days) $51.25 3 Day Express Coggins (Additional charges for next day. ) $78.00 Drug Screen $288.50 + Shipping Digital Radiographs* Both Front Feet (12views) $644.50* Both Knees (10 views) $562.50* Both Hocks (8 views) $460.50* Both Stifles (6 views) $358.50* Both Front Fetlocks (8 views) $460.50* Both Hind Fetlocks (8 views) $460.50* * A $51.00 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 $51.00. ** There will be an Office Visit charge or a Farm Call charge (base on mileage), on all Pre-Purchase exams. Sports Medicine Ultrasound $313.50 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 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 AgentDate 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.CAPTCHAThis field is hidden when viewing the formPurchaserThis field is hidden when viewing the formSeller