Pre-Purchase Exam Download Fillable Pre-Purchase Exam Form 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 NumberCell 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 NumberCell NumberFax NumberEmail Trainer InfoContact Name First Last CellAlternative #Horse InfoRegistered NameHorse's Barn NameColorDate of Birth Date Format: MM slash DD slash YYYY GenderMareGeldingStallionBreedPresent UseIntended UsePurchaser, please check the boxes for each procedure you would like performed: ExamPre-Purchase Exam $362.00Airway 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 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 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 OptionsUse 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.CAPTCHAPurchaserSeller