Pre-Purchase Exam Disclosure Form (BUYER)

Note: At High Country Veterinary Services, we endeavor to provide a thorough exam of those organ systems available for examination, in order to provide an accurate picture of the horse in its current condition. We cannot predict the future, and our report is not intended to be a guarantee of future performance. We are not responsible for determining the accuracy of any information provided by the seller of the horse in question.

Purchaser Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Purchaser Phone Number*

Purchaser E-mail*

example@example.com

Purchaser Agent (if applicable)

First NameLast Name

Agent Phone Number

Please enter a valid phone number.

Agent Email

example@example.com

Seller Name*

First NameLast Name

Seller Phone Number*

Please enter a valid phone number.

Seller Email*

example@example.com

Date of Examination

Date

Doctor completing exam

Name of Horse*

Has this horse been seen by High Country Veterinary Services, LLC or any of its Veterinarians in the past?*

YesNoUnknown

Physical Address Where Exam Will Take Place*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Age of Horse*

Sex*

MareGeldingStallionUnknown

Breed*

Color*

Date of most recent vaccines*

Date

Vaccines Given

Previous Use of Horse

Intended Use of Horse*

Do you intend to breed this horse?*

YesNoMaybe

Is this horse a resale prospect (investment)?*

YesNo

If yes, what time frame?

Are radiographs requested as part of the exam?*

YesNoIf veterinarian feels necessary

If yes, which specifically would you like?

Are you interested in special diagnostics (endoscopy, ultrasound, Lab work, etc.)*

YesNoIf veterinarian feels necessary

If yes, which of the following?

If other or lab work, please define.

Are you interested a drug screen?*

YesNoIf veterinarian feels necessary

Would you like a written estimate prior to this appointment?*

YesNo

Please list any special concerns or other comments here:

A pre-purchase exam should be used along with the buyer’s common sense and knowledge regarding the horse. The exam is just one of several tools used to understand a horse’s unique problems and how best to manage those issues in light of age, history, performance record, prior health records, and intended use. The exam does not waive buyer’s duty to exercise buyer’s own due diligence in investigating the horse’s prior history. IT IS A BUYER’S ULTIMATE RESPONSIBILITY TO DETERMINE IF A HORSE IS SUITABLE FOR BUYER’S INTENDED USE AND PURPOSE. For this reason, it is suggested buyer request seller’s written authorization to release horse’s prior treatment records from the relevant veterinary clinic(s). Similarly, per AAEP guidelines, any known invasive surgery, disease, injury or congenital defect of the horse which is not readily apparent should be disclosed by Seller and/or Seller’s Agent to the intended buyer and/or this veterinary practice.

During the exam, we may determine issues that suggest the need for additional testing methods or procedures. Buyer may ask that certain procedures not be performed for a variety of reasons. Limitation of recommended diagnostic tests or procedures may impact the ability of this veterinary practice to identify potentially relevant health or performance issues for this horse. Blood tests are recommended in all instances, and the clinic will hold same for a period of thirty (30) days following the exam.

Buyer has requested a licensed veterinarian of High Country Veternary Services (HCVS) to perform a Pre-Purchase Examination on the above named horse. Buyer has also been made aware of any possible conflicts of interest if present, such as being the seller's veterinarian which could introduce conscious or unconscious bias to the examination, and has still made the decision to retain our services regardless of this potential conflict of interest.

In order for the undersigned to obtain the benefit of a fee which includes a lesser allowance for risk funding, the undersigned agrees to limit HCVS liability arising from its professional acts, errors or omissions related to this pre-purchase examination such that the total liability of HCVS shall not exceed total fees paid for the examination services rendered in this particular pre-purchase examination.

Signature of Buyer*

Pre-Purchase Exam Disclosure Form

Purchaser Information

Seller Information

Patient Information