Client Info / Pre-Purchase Form CLIENT INFO / PRE-PURCHASE Appointment Date Month Day Year Attending Doctor Buyer / Client Name PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Seller / Agent Name PhoneHorse Name Barn Name Breed Color Sex Male Female AgeIntended Discipline Consent SectionBy checking this box, I agree to the following statement:(Required) I AgreeI hereby consent and authorize the veterinarians and staff of McKinlay and Peters Equine Hospital to perform the above pre-purchase. By checking this box, I agree to the following statement:(Required) I AgreeI have been provided a copy of the Pre-Purchase Price list.I choose the following in addition to the base pre purchase exam: Level 1 Level 2 Level 3 Please forward radiography and/or reports to consulting DVM: By checking this box, I agree to the following statement:(Required) I AgreeI understand as part of the pre-purchase examination blood will be drawn for any future blood tests. CBC Blood, Chemistry, Serology and or drug screens can be added for an additional fee to the base pre-purchase exam package.By checking this box, I agree to the following statement:(Required) I AgreeI understand that any estimates provided to me may not be exact and that other expenses may be incurred in the course of treatment. I agree to be responsible for payment of any and all charges associated with treatment of the above-named animal.By checking this box, I agree to the following statement:(Required) I AgreeA credit card on file is required for all pre-purchase examinations along with a $500 deposit. Payment in full is required at the time of service.Signature SectionSignature(Required)Date(Required) Month Day Year By signing above and checking this box, I agree to the following statement:(Required) I AgreeI have read and understand this authorization and consent. CAPTCHA Δ
