Pre-Purchase Buyer Request Name of Horse*Requested Date of Exam* MM slash DD slash YYYY Intended Use*Age of Horse*Buyers Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please check all the services that you would like to have performed at the time of the exam:Clinical Examination Clinical Examination: This examination includes a general health exam evaluating the eyes, heart, lungs, gastrointestinal and musculoskeletal systems. A dynamic evaluation of the horse’s gait will be done to assess for lameness or other abnormalities. Radiographs: (Please check only items wanted) Only areas of concern: When areas of concern are identified on clinical exam and x-rayed, these will be charged per radiographic view. Standard Screening Radiographs: This package includes 18 radiographs at a discounted rate. Views in this package usually include 4 views of each front foot, laterals of each fetlock, and 3 views of each hock. Comprehensive Screening Radiographs: This package includes 32 radiographs. Views in this package usually include 4 views of each front foot, 4 views of each front fetlock, 2 views of each hind fetlock, 4 views of each hock and 2 views of each stifle. Neck Radiographs Back Radiographs (Dorsal Spinous Processes) Other (Please Specify) Please SpecifyBlood Tests Drug Screen CBC & Chemistry Coggins Other Services Endoscopy (Please specify below) Insurance Form Completion Export Form to United States Completion Endoscopy – Please SpecifyWho to contact with findings* First Last Phone*Date* MM slash DD slash YYYY Signature*EmailThis field is for validation purposes and should be left unchanged.
