PPE Form Pre-Purchase Examination Consent FormDate *Buyer's Name: *Buyer's Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryBuyer's Phone *Buyer's Email Address *Name and phone for buyer's trainer, if involved: Name of barn/farm/person where horse currently resides *Address where horse currently resides *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryPhone number of person where horse is currently residing *Horse's Name: *Horse's Date of Birth *Breed *Sex *MareStallionGeldingImportant Notice The Pre-purchase exam consists of a clinical exam and a moving evaluation. The clinical examination consists of evaluation of the horse’s respiratory, cardiovascular, musculoskeletal, ophthalmic, and gastrointestinal systems. During the moving evaluation, the horse will be examined at a walk and trot in hand, and if possible, longed or circled at the walk and trot in both directions. Providing circumstances permit, flexion tests of the forelimbs and hind limbs will be performed and hoof testers will be applied to all four feet. If the buyer elects to stop the exam at any point due to a perceived lameness, we will not continue to examine the other aspects of the horse. We offer several other possible components to our exam. Please select the services which you would like for us to provide at the time of your pre-purchase exam. Based on the results of the clinical and moving exams, the veterinarian may recommend additional diagnostic tests at the time of the examination to further evaluate exam findings. The pre-purchase exam is expressly limited by your statements and instructions on the depth of the examination desired and the specific tests that you have requested.Radiographs Requested: *Front feet/ NavicularFront fetlocksKneesStiflesHocksRear fetlocksNeckBackI do NOT want radiographsOther Procedures Requested CBC/ChemistryUpper Airway EndoscopyCogginsDrug ScreenHealth CertificateI, the Buyer, have requested that Springhill Equine Veterinary Clinic perform a Pre-Purchase exam on the aforementioned animal. The purpose of this pre-purchase examination is to offer a professional opinion as to the present general health, condition, and serviceability of the above named animal. Professional opinions and judgments as to the future serviceability and soundness of this animal may be offered as possible help and assistance to the buyer or their agent in the decision to accept or reject this animal. The horse will not receive a “pass” or “fail.” The decision to buy can only be made by the buyer. Only the buyer can decide if the horse’s talent, suitability, disposition, or value meet his/her satisfaction.I understand that the examining veterinarian can in no way predict the future performance or soundness of the aforementioned animal, and makes no claims to do so. No other specialized examination techniques were included in this exam unless specifically requested and recorded. If the buyer wishes to obtain a warranty covering exact age, height, freedom from vices, the non-administration of drugs prior to this examination, future soundness, or the animal’s breeding or performance history, such warranty should be obtained from the seller as these are not the responsibility of the veterinarian. Some subtle internal medical or musculoskeletal problems are difficult to diagnose or will not be apparent on a routine pre-purchase examination. Recurrent colic, tying up, intermittent heaves/equine asthma, pregnancy, impaired vision, anhydrosis, and subtle transitory lameness are some of the conditions that may not be apparent on these exams. EPM can only be definitively diagnosed by spinal tap procedure.Buyer's initials *Please type your initials to indicate that you have read and agree with the preceding statement.MRI *For an additional $900 a limited MRI study can be done of the front feet. This procedure assists in identifying soft tissue changes of the feet that may not be readily observed on radiographs. This price does not included shipping to and from the hospital for the procedure.I request an MRII decline the MRI Payment InformationCardholder Name *Credit Card Number *Expiration Date *Security Code *Billing Zip Code *Distribution of Information I understand that it is the veterinarian’s responsibility to provide information to Buyer, who will then use said information as they see fit. The information generated by this exam belongs to Buyer, but Springhill Equine may share this information with the seller of the horse at Buyer’s request. This veterinarian will NOT “Pass” or “Fail” this horse, but will only provide any and all evaluative findings. I also understand that this horse’s monetary value and suitability for any particular discipline are NOT part of this evaluation.Buyer's Electronic Signature *Please type your name as an authorizing electronic signature.Date of Signature *Please list any comments or special notes: VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
