Pre-Purchase Form in Summerville, SC - Charleston Equine Clinic

Purchasers’ Name:

Appointment Date:

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone:

Cell Phone:

Email Address:

Forward written report and/or radiographs to consulting veterinarian:

Consulting veterinarian’s email address:

Seller’s Name:

Phone:

Location of Horse:

Horse’s Name:

Age:

Sex:

Breed:

Color:

Discipline horse to be used for

I choose the following additions: (Initial next to each selection)

Digital Coggins

Chemistry

Elisa Digital Coggins (Rush)

CBC

Drug Screen Level 1

Drug Screen Level 2

Ultrasound: Repro/other

Radiographs:

Level 1 (6 views)

Level 2 (12 views)

Level 3 (24 views)

Level 4 (36 views)

# of Extra

I 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

Date

*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:

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

Date