Pre-Purchase Consent Form Name of Horse * Date of Appointment * MM DD YYYY Buyer Name * Authorized Representative * Phone * (###) ### #### Email * PLEASE NOTE: This examination is solely intended to assist a prospective purchaser. This examination is done at the request and expense of the prospective purchaser and is intended only for use by the said prospective purchase. All exam findings recorded by the examiner are based on his/her opinion, to the best of his/her knowledge and upon information available at the time of the exam. Many medical or musculoskeletal conditions are difficult to diagnose or may go unrec-ognized on a routine pre-purchase examination. If the horse has been ridden at the level and intensity for which it is being purchased, many of these conditions can be recognized or ruled out. Neither the examiner nor the report based on the examination make any representations concerning purchase price, value, use by a particular rider, suitability or rideability of the horse being examined. Any decision concerning purchase of the horse is solely the responsibility of the prospective purchaser. I understand the above statement. * Yes PLEASE SELECT DESIRED SERVICES / TESTS / EXAMS LISTED BELOW: * Pre-Purchase exam - $550 CBC / Fibrinogen / Chem screen - $185 Drug Screen - $280 Coggins - $65 EPM - $280 Lyme Multiplex - $122 Ultrasound (only if clinically indicated) - $185 RADIOGRAPHS - SELECT DESIRED RADIOGRAPHS BELOW: * Standard radiographs (38 views) include the following: • Front feet, 4 views x 2 • Front fetlocks, 4 views x 2 • Hocks, 4 views x 2 • Hind fetlocks, 4 views x 2 • Stifles, 3 views x 2 Standard Radiographs, 38 views - $2,090 BACK Radiographs, 4-5 VIEWS - $220 NECK radiographs, 4-5 VIEWS - $220 ADDITIONAL RADIOGRAPH(S) - PER VIEW - $53 discuss selection of radiographs after clinical exam Riding: I understand the exam will require riding and will be appropriately prepared for such. * Yes Payment authorization: I understand a valid credit card number will need to be supplied and that card will be charged for the full amount of the pre-purchase exam with in 24 hours of the completed exam. * Yes Thank you! © 2025 Chesapeake Equine Performance. All Rights Reserved.
