Country View Equine Clinic

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Compassionate veterinary care for your horse

Pre-Purchase Authorization Form

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Pre-Purchase Information

Included in Base Pre-Purchase Examination (call for pricing)

Physical Examination

Includes complete physical exam (ophthalmic exam, oral exam, auscultation of heart/lungs, hoof exam, basic neurologic exam

Dynamic Exam

Basic lameness exam with flexion testing

Bloodwork Storage

Blood is collected and stored for 2 months in case any testing is requested.

Common Additional Fees (call for pricing)

Bloodwork

Coggins in buyer's name, CBC/Chemistry, disease specific bloodwork, drug testing

Expedited Lab

Select bloodwork returned within 24 hours

Health Certificate

Required with a current coggins' test for travel out of state. Valid for 30 days.

Radiographs

Charged per view. Commonly requested views include: Farrier Radiographs of front feet (2 views per foot), Hock Series (2-4 views per hock), Stifle Series (2-3 views per stifle), Neck Series (6-7 views), Back Series (3-5 views)

Vaccination

Buyer can request vaccines to be administered by the prepurchase veterinarian with permission from the seller.

Sedation

If deemed necessary, the prepurchase veterinarian will make this known and permission from the seller and buyer will need to be given prior to sedating. The buyer is responsible for charges associated with sedation.

Stable Call/Mileage

Stable call levels are zoned. Pre-purchase exams outside of our practice area are granted seasonally on a case-by-case basis and additional mileage fees are applied

Appointment Date

MM

DD

YYYY

Buyer Name *

First Name

Last Name

Buyer Phone *

(###)

###

####

Buyer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Buyer Email *

Seller Name *

First Name

Last Name

Seller Phone

(###)

###

####

Horse Name *

Barn Name, Registered Name (if applicable)

Breed

Color

Sex

Date of Birth

If exact date of birth is unknown, select January 1st of the estimated year of birth.

MM

DD

YYYY

Intended Use/Discipline

Would you like to receive an estimate prior to your pre-purchase? *

If yes, select the items you would like included in your estimate

Stable call and base examination will automatically be applied to estimate. If you would like something included that is not in this list, please call or email CVEC with additional items.

Coggins

Expedited lab fees

CBC/Chem

Disease specific bloodwork

Drug Testing

Health certificate - interstate

Vaccinations

Radiographs (please list in text box below)

Sedation

Breeding soundness exam (mares only)

The following radiographs are requested to be performed:

Email (Second Opinion)

Please forward the radiographs to the following doctor/hospital email address for additional review

By checking the following, I acknowledge that I have read and understand this form and consent to the following: *

All fields must be checked

I authorize and consent to the veterinarians and staff at Country View Equine Clinic to perform the prepurchase on the horse listed above.

I understand that any estimates provided to me may not be exact and that other expenses may be incurred in the course of the examination. I agree to be responsible for payment of any and all charges associated with the prepurchase examination of the animal listed above

I understand that a credit card is required to be put on file for all prepurchase examinations. Payment in full is required at time of service, which will be applied to this credit card unless I arrange to pay by cash or check at the time of the examination.

Signature *

By typing my full name in the box below, I hereby acknowledge that all of the above information that I have provided is true and accurate to the extent of my knowledge.

Thank you!