Pre-Purchase Form Purchasers’ Name:(Required)Appointment Date: MM slash DD slash YYYY Address(Required) Street Address City State / Province / Region ZIP / Postal Code Home Phone:Cell Phone:(Required)Email Address:(Required) Forward written report and/or radiographs to consulting veterinarian:Consulting veterinarian’s email address: Seller’s Name:(Required)Phone:(Required)Location of Horse:(Required)Horse’s Name:(Required)Age:Sex:Breed:Color:Discipline horse to be used forI choose the following additions: (Initial next to each selection) Digital Coggins Chemistry Elisa Digital Coggins (Rush) Elisa Digital Coggins (Rush) CBC Drug Screen Level 1 Drug Screen Level 2 Ultrasound: Repro/other Radiographs: Pricing available upon requestRadiographs: Level 1 (6 views) Level 2 (12 views) Level 3 (24 views) Level 4 (36 views) # of Extra Pricing available upon request# of ExtraI hereby authorize the veterinarians of Charleston Equine to examine the horse listed above for a pre-purchase examination. I assume responsibility for all charges incurred for the selections that I have made above. I also understand that these charges must be paid for at the time of service. I also understand that any estimates that were given may not be the total cost as there may have been other expenses incurred during the examination.Signature(Required)Date(Required) MM slash DD slash YYYY *If purchaser is not able to be present at the time of exam a credit card must be left on file. You may also call in your credit card number to be held on file before the service date. Credit Card Type:(Required) Visa Mastercard Discover AmEx CC on file Credit Card Number:Expiration Date:Card Identification Number:I authorize Charleston Equine Clinic to charge the credit card listed above/or on file for all expenses incurred for the pre-purchase base exam and selections chosen above. Signature(Required)Date(Required) MM slash DD slash YYYY
