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Name *

First Name

Last Name

Phone Number *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name *

First Name

Last Name

Phone Number

(###)

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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

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I agree that by submitting this electronic form, that I understands all terms stated above, that I am electronically signing the form and I, the undersigned declare that the information is true to the best of my knowledge.

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