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Name *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name *

First Name

Last Name

Phone Number

(###)

###

####

Date of Birth *

Put approximate year of birth if unknown/unsure

MM

DD

YYYY

Gender *

Mare

Gelding

Stallion

Have you tried this horse? *

Yes

No

Will you (the buyer) be present for the pre-purchase examination? *

Yes

No

Will the seller be present for the pre-purchase examination? *

Yes

No

If yes, do you authorize the findings of the pre-purchase examination to be discussed with the veterinarian with the seller present?

Yes, I authorize discussion of pre-purchase findings with the seller present

No, I do not authorize discussion of pre-purcahse findings with the seller present

Radiographs:

Front Feet

Hind Feet

Naviculars

Front Fetlocks

Hind Fetlocks

Knees

Hocks

Stifles

Laboratory Testing:

Equine Blood Screen (CBC, Chemistry, Fibrinogen)

NSAID Testing (drug residue for Bute or Banamine)

Fecal Egg Count

Fecal Ulcer Test

Coggins Testing (Equine Infectious Anemia)

Endoscopy:

Upper airways, larynx, guttural pouch

Ophthalmology:

Eye dilation for lens and retinal exam

Fluorescein stain

Reproduction:

Mare ultrasound + breeding soundness exam

Genetic Testing

Hyperkalemic Periodic Paralysis

*

I understand that veterinary pre-purchase examinations do not warrant the suitability of the horse for the purchase intended and is expressly limited by my statements and instructions on the depth of the examination desired, the specific tests which I have requested are preformed and the fee I have agreed to pay. The veterinarian will provide me with findings of the examination but the ultimate decision to purchase the horse is my, the proposed purchasers, only. I agree that by typing my name and submitting this electronic form, that I am electronically signing the form and I, the undersigned, declare that the information provided is true to the best of my knowledge.

Signature *

First Name

Last Name