Pre-Purchase Exam Form

6320 Darling Rd. Blacklick, OH 43004
Office (614) 540-0040
Pre-Purchase Exam Form
Buyer Name:
Phone Number:
Format: (000) 000-0000.
Buyer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Buyer's email:
example@example.com
Buyer's Trainer/Agent Name (if applicable):
Seller Name:
Seller's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Seller's Trainer/Agent Name (if applicable):
Address of Exam Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who will be present at exam:
There will be an arena at the place of examination:
Is the arena or other area of exam covered by a roof:
If you selected "NO" to either of the above, please be advised that we may not be able to
accommodate a full exam without a proper facility, especially in the event of inclement weather.

Horse Information
Name/Barn Name:
Registered Name:
Registration Association:
Date of Birth:
Approx. Age:
Sex:
Breed:
Color:
Height:
Current Use:
Intended Use:
Known Medical Conditions or Medications:
Examination Options:
The Comprehensive Pre-Purchase Exam will be completed by nature of this agreement. Please choose any further optional services as desired.
Comprehensive Pre-Purchase Exam: $472.47 (not including farm call fee)
Includes:
History: review of horse's pertinent history if available by seller
Physical Examination: conformation, body condition, eyes, hooves, cardiovascular, respiratory, unsedated oral, digestive, nervous, and musculoskeletal systems. Urogenital or reproductive may not be examined unless requested.
Soundness Examination: gait is evaluated on lunge line and in hand with joint flexions, on surfaces that are available and safe
Flexion Tests: forced joint flexion with examination of gait before and after flexion is performed only if patient is able to jog in hand, and patient behavior allows for tests

Optional Services:
Please note that these services are not included in the Comprehensive Pre-Purchase Exam but are offered for an additional cost at the price listed.
Radiographs:
Lab work:
Other Requests (please describe your request and we will try to accommodate to the best of our ability):

Payment Terms
Payment for the pre-purchase examination and any authorized diagnostic services is due in full at the time services are rendered unless otherwise agreed in writing. The buyer remains financially responsible for all charges associated with the examination, including services authorized by the buyer's trainer, agent, or representative. For security reasons, Bella Vista Equine Veterinary Services does not collect or store credit or debit card information on this form. Payment information will be provided by telephone prior to the time of the examination.
Cancellation Policy
Appointments canceled with less than twenty-four (24) hours' notice may be subject to a cancellation fee of $100.
Authorization to Charge Payment Method on File
For security reasons, credit card information is not collected on this form. Payment information will be provided by telephone prior to or at the time services are rendered. The client authorizes Bella Vista Equine Veterinary Services to charge the card for approved veterinary services. By signing below, the buyer authorizes Bella Vista Equine Veterinary Services to charge the payment method provided separately by telephone for:
- The pre-purchase examination
- Any diagnostic services authorized in advance or during the examination
- Applicable call fees
- Applicable cancellation fees
Acknowledgment and Agreement
The buyer acknowledges that:
- They are responsible for payment of all fees associated with this pre-purchase examination
- Diagnostic results and records may be withheld until payment is received

- This billing authorization is separate from, and in addition to, the clinical disclosures and limitations of the pre-purchase examination described elsewhere in this form
Buyer Signature:
Date:

MonthDayYear
Date
Should be Empty:

Pre-Purchase Exam Form

Horse Information

Examination Options:

Includes:

Optional Services:

Payment Terms

Cancellation Policy

Authorization to Charge Payment Method on File

Acknowledgment and Agreement