PPE Test Page

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
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 $373.00
Airway Evaluation
- In-Clinic Video Endoscopy $297.00
- Limited Field Endoscopy $Call For Pricing
- Dynamic Endoscopy $349.50
Laboratory Testing
- Complete Blood Count $77.50
- Health Certificate (Additional charges for next day.) $23.75
- Chemistry Profile: In-House Lab STAT $204.25
- Chemistry Profile: Outside Lab $102.75
- Standard Coggins Test (5-7 days) $43.50
- 3 Day Express Coggins (Additional charges for next day. ) $66.50
- Drug Screen $248.50 + Shipping
Digital Radiographs*
- Both Front Feet (12views) $529.00*
- Both Knees (10 views) $442.00*
- Both Hocks (8 views) $355.00*
- Both Stifles (6 views) $268*
- Both Front Fetlocks (8 views) $355.00*
- Both Hind Fetlocks (8 views) $355.00*
* A $37.00 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 $43.50.
** There will be an Office Visit charge or a Farm Call charge (base on mileage), on all Pre-Purchase exams.
Sports Medicine Ultrasound
- $270.25 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
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
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Seller
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