Northwest Equine Veterinary Associates, INC. P.S.
Steven Latimer, DVM Chantal Rothschild, DVM ACVIM Erin Kennedy, DVM
PO Box 445 Hobart, WA 98025
Phone: 425 432 1914 Fax: 425 432 5306
nw-equine@msn.com www.nwequinevet.com
2011 BUYERS STATEMENT FOR PRE-PURCHASE EXAM
Date:
Name:
Address:
Telephone: Home ( ) - Work ( ) -
Cell ( ) - Fax ( ) -
Email:
Horse being examined:
Seller or Agent:
Intended Use of the horse:
Intended rider’s experience level: Is rider a child?
How long have you been acquainted with the horse?
Have you ridden this horse? Yes No If yes, in what fashion?
How do you rate the suitability of this horse for the intended purpose? (please choose one)
Exceptional Adequate Marginal
Of what relative importance are the following to you? Please mark with an “X”:
Very Important Important Not Important
Appearance
Blemishes
Performance
Temperament
Fertility
Please note any observations or concerns you may have regarding this horse:
What type of care (stabling) is anticipated for the horse?
Intensive (continual care and supervision)
Average (stabled daily for feeding, etc.)
Casual (on pasture most of the time)
*Important note: This form (and the Seller forms) must be completely filled out AND received by our office up to 24h
prior to appointment. Otherwise, appointment will be cancelled and a cancellation fee will incur. We hope for your
understanding. All forms can also be downloaded from our website: http://www.nwequinevet.com/forms
Concerning the Veterinary Pre-purchase examination:
Will you be at the appointment: Yes No
Laboratory work to be run on this horse:
Complete Health screen (CBC/chemistry): Yes No Coggins test: Yes No
Drug screen: Yes No Fecal sample for parasite test: Yes No
Others:
Radiographs to be taken (please note sedation is typically required for these)*:
*Please inquire about our discount packages for these…
Laminitis/Navicular series: Yes No
Front fetlocks: Yes No
Front knees: Yes No
Hind fetlocks: Yes No
Hocks: Yes No
Stifles: Yes No
A joint (s) where the horse flexes positive: Yes No
Others:
Do you want a fertility exam performed? Yes (if so, please circle below all desired test) No
Mares: ultrasound of uterus and ovaries vaginal / cervical speculum exam / uterine culture
/uterine cytology / uterine biopsy /
Stallions: external genitalia exam / semen collection and evaluation
Any other tests you would like performed:
Ultrasound: Yes No Endoscopy : Yes No
Others:
Do you have a veterinarian you would like the final report and/or radiograph images sent to?
Name:
Address:
Phone numbers: Work: ( ) - Cell: ( ) -
Fax ( ) -
Email:
*Important note: This form (and the Seller forms) must be completely filled out AND received by our office up to 24h
prior to appointment. Otherwise, appointment will be cancelled and a cancellation fee will incur. We hope for your
understanding. All forms can also be downloaded from our website: http://www.nwequinevet.com/forms
The veterinary purchase examination does not warrant the suitability of the horse for the purpose
intended and is expressly limited by my statements and instructions on the depth of the
examination desired, the specific tests which I have requested be performed and the fees I have
agreed to pay.*
In exchange for providing this Statement, Buyer waives any claim against said Veterinarian and/or
clinic for any future problems this subject animal may develop.
Please note this examination in no way represents a warranty of soundness or unsoundness and
represents only the opinion of the examiner. It is limited by the limitations of time and facilities.
One cannot protect oneself against animals on medication or intermittent problems to which
animals are subject.
Signature: Date:
*You are entitled to a complete cost estimate of all procedures. It is your responsibility to ask for
the cost estimate, otherwise it is assumed that you approve of the procedures you are requesting
and the resulting cost.
We kindly request that payment arrangements for the exam and diagnostics be made prior to appointment.
Credit Card information:
Name on card: __________________________________________
Card type: Visa Master Card American Exp Discovery
Card #:
Last 3 digits (security code):
Expiration date:
Billing Address:
Signature:
*Important note: This form (and the Seller forms) must be completely filled out AND received by our office up to 24h
prior to appointment. Otherwise, appointment will be cancelled and a cancellation fee will incur. We hope for your
understanding. All forms can also be downloaded from our website: http://www.nwequinevet.com/forms