Pre-purchase Exam Request Form

Name

Phone

Address

Email Address

Will the potential buyer be present for the exam? Will the potential buyer be present for the exam? Yes No

Authorized agent and agent’s relationship to buyer: I (the buyer) authorize my named agent to make decisions about the examination/ancillary testing in my place: Authorized agent and agent’s relationship to buyer: I (the buyer) authorize my named agent to make decisions about the examination/ancillary testing in my place: Yes No

Horse’s Registered/Show name (if applicable)

Horse’s Barn Name

Age

Color

Breed

Gender Gender Gelding Mare Stallion

Current Use of the Horse:

Buyer’s Intended Use of Horse

Current Owner’s Name:

Location for Exam: Location for Exam: Haul to Clinic (705 N Main St, Lodi, WI 53555) At Horse’s Location. Add address in next field.

Location

Date or date range you are requesting to have the exam performed:

Doctor Preference: Doctor Preference: No preference Brauer, Savannah Kolb, Dave Livesey, Kathryn Lockard, Emily Mason, Jon McKittrick, Corinne Meyer, Dean Wagner, Laura

Do You Want X-rays: Do You Want X-rays: No Yes

If yes, please select all that apply: If yes, please select all that apply: Hocks Stifles Front feet complete (includes navicular views) Front feet limited (laterals for farrier angles, laminitis) Other (please list):

Any Concerns to Share with the Veterinarian?:

Will you need any of the following (additional costs apply): Will you need any of the following (additional costs apply): Health Certificate Coggins Drug Screen Fecal Other

What other additions would you like to add?

Do you have a veterinarian you would like the final report and/or radiograph images sent to? Do you have a veterinarian you would like the final report and/or radiograph images sent to? No Yes

Please include the clinic, veterinarian, email, and phone number.

A pre-purchase examination is a thorough physical examination stating an opinion of the horse on the day of the exam. The examination is not intended to be used as a prognosis for future health, soundness or a warranty for the horse’s suitability for any particular future use or purpose. The veterinarian’s job is neither to pass nor fail the animal being examined. By checking the box below you are indicating that you understand that there are limitations to the pre-purchase evaluation and certain conditions may not be detectable on the day of the examination. You also agree not to hold Lodi Veterinary Care liable for conditions that may present themselves in the future that could affect performance or resale. Ultimately, the decision to purchase the horse can only be made by the prospective buyer: A pre-purchase examination is a thorough physical examination stating an opinion of the horse on the day of the exam. The examination is not intended to be used as a prognosis for future health, soundness or a warranty for the horse’s suitability for any particular future use or purpose. The veterinarian’s job is neither to pass nor fail the animal being examined. By checking the box below you are indicating that you understand that there are limitations to the pre-purchase evaluation and certain conditions may not be detectable on the day of the examination. You also agree not to hold Lodi Veterinary Care liable for conditions that may present themselves in the future that could affect performance or resale. Ultimately, the decision to purchase the horse can only be made by the prospective buyer: By checking the box, I (the buyer) indicate that I have read and understood the above information.