Buyer Name

Email Address

Address

City

State

Zip Code

Phone

Agent/Trainer Name

Agent/Trainer Phone

Address where horse is located

City

State

Zip code

Horse's registered name

Horse's Barn Name

Horse's date of birth

Horse's breed

Horse's gender Horse's gender Mare Gelding Stallion

Horse's color

Horse's Medical History

Current Owner Name

Current Owner Phone

Current Agent/Trainer Name

Current Agent/Trainer Phone

What is the horse's intended use?

Do you have any concerns about this horse?

Radiograph acknowledgement Radiograph acknowledgement The number of radiographs required to fully image an area vary by anatomical region, and not all regions can be fully radiographed. It is your responsibility to discuss the radiographic options with the veterinarian so that you fully understand the limitations and costs of each choice. By checking the box, you acknowledge that the costs of radiographs will depend on your choices.

Please select all the radiographs you want us to take: Please select all the radiographs you want us to take: Front feet Navicular Front fetlocks Knees (carpi) Hind feet Hind fetlocks Hocks Stifles Neck Back I DECLINE ALL RADIOGRAPHS

Desired bloodwork Desired bloodwork Coggins CBC Chemistry Drug Screen I DECLINE ALL BLOODWORK

Will you require a health certificate if you purchase this horse? Will you require a health certificate if you purchase this horse? Yes No

Equine Pre-Purchase Examination Liability Release Agreement. All boxes must be checked. Equine Pre-Purchase Examination Liability Release Agreement. All boxes must be checked. I, the buyer, hereafter "buyer" am the prospective purchaser. Buyer acknowledges that Dr. VanWinkle, of Gulf Coast Equine Veterinary Services, Inc., has agreed to perform a pre-purchase examination at my request on the horse listed above. Gulf Coast Equine Veterinary Services, Inc. will perform a pre-purchase examination of the horse listed on this form. The scope of the examination and the selection of diagnostic tests chosen shall be determined by buyer in consultation with Gulf Coast Equine Veterinary Services, Inc. The veterinarian who conducts the pre-purchase examination will provide you with information regarding any existing medical problems and the horse's overall health and condition on the given day of the examination. The examination is not intended to be used as a prognosis for future health, soundness, or a warranty for the horse’s suitability for any particular future use or purpose. The veterinarian's job is neither to pass nor fail the animal being examined. The determination by buyer to purchase the animal examined is solely buyer's choice and responsibility. The buyer should be aware that this examination does not encompass an in-depth evaluation of the horse’s temperament, ability, or aptitude for a particular discipline. It describes the horse’s health and soundness the day of the examination. A routine pre-purchase examination may not reveal subtle unsoundnesses, especially if the horse has not been in hard/consistent work in the preceding months. Some conditions, such as mild recurrent airway obstruction (“heaves”), mild vision impairment, early PPID (Cushings Disease), digestive disorders predisposing to colic, and muscle disorders such as equine polysaccharide storage myopathy (“tying up”) may not be apparent during an examination. Buyer acknowledges that a material condition of Gulf Coast Equine Veterinary Services, Inc.’s agreement to perform this pre-purchase examination is the buyer's agreement to release, waive and discharge Gulf Coast Equine Veterinary Services, Inc., its veterinarians and employees from all claims arising directly or indirectly from the performance of the pre-purchase examination; this is a promise by the buyer not to sue. I have read this agreement, "Equine Pre-Purchase Examination Liability Release Agreement," and fully understand its terms. I intend my electronic signature to be a complete and unconditional liability release to Gulf Coast Equine Veterinary Services, Inc., its veterinarians and staff.

Type full name as valid electronic signature