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

Seller Name *

First Name

Last Name

Seller Phone

(###)

###

####

Date of Birth

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

MM

DD

YYYY

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)

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.