ANGELA N. CHENAULT, D.V.M.
LA PALOMA EQUINE CLINIC
P.O. BOX 30
34626 BRUMLOW ROAD
WALLER, TEXAS
77484
936-931-9100
281-966-6996 FAX
BUYER’S
STATEMENT
PROPOSED BUYER’S NAME:_____________________________________________________
ADDRESS: ____________________________________________________________________
TELEPHONE
NUMBER(S):________________________________________________________
AGENT’S NAME:________________________________________________________________
ADDRESS:
____________________________________________________________________
TELEPHONE
NUMBER(S):________________________________________________________
SELLER’S NAME:
______________________________________________________________
TELEPHONE
NUMBER(S):_______________________________________________________
HORSE’S
NAME: ______________________________________________________________
AGE:________ SEX:___________ COLOR:_______________ BREED:___________
MARKINGS:___________________________________________________________________
INTENDED
USE:_______________________________________________________________
HOW
LONG HAS BUYER KNOWN THE HORSE?____________ WILL THE BUYER BE
PRESENT AT THE EXAM?___________ WILL
AN AGENT BE PRESENT?_____________
(IT IS IN THE BEST INTEREST
OF THE BUYER TO BE PRESENT AT THE EXAM, IF THIS IS NOT POSSIBLE, THEN THE BUYER
SHOULD HAVE AN AGENT PRESENT). IF YOU
HAVE ANY QUESTIONS, CALL THE CLINIC NUMBER LISTED ABOVE.
SPECIAL EXAM OR TEST REQUESTED: (PLEASE INITIAL)
1.
INITIAL PHYSICAL
EXAM:_________ ($150-200 depending on
extent of exam)
2.
RADIOGRAPHS
($25.75 PER VIEW ON FILM/$35.00 PER VIEW DIGITAL):________
NONE
(UNLESS LAME):______
FRONT FEET:_________ HOCKS:_________ OTHER:_________
3.
ENDOSCOPY ($105.00):
___________
4.
BLOOD TEST: CBC ($32.00):_____ CHEMISTRY
SCREEN ($65.00):________
COGGINS ($27.50):_____________ OTHER: ____________
5.
BLOOD / URINE
DRUG SCREEN ($170.00 - $200.00):____________
6.
URINALYSIS ($35.00):
____________
7.
FECAL EXAM ($32.00):_________
8.
ANY OTHER
SPECIAL REQUEST: _____________________
PAGE
2 OF 2 BUYER’S
STATEMENT
FEES MUST BE PAID IN ADVANCE UNLESS
OTHER ARRANGEMENTS HAVE BEEN MADE.
PAYMENT IS
DUE AT THE TIME OF THE EXAM: CASH:______ CHECK:____ CREDIT CARD:______
CREDIT CARD CCV: ______ CREDIT CARD NUMBER:_____________________ EXP
DATE:______
WILL INSURANCE BE REQUIRED
ON THE HORSE?_______ IF
SO, PLEASE PROVIDE NAME AND CONTACT NUMBERS:
________________________________________________
WILL RADIOGRAPHERS BE SENT
TO BUYER’S REGULAR VETERINARIAN?______________
ADDRESS:
__________________________________________________________________
PHONE NUMBER:
_____________________
THERE WILL BE ADDITIONAL
CHARGES FOR FEDERAL EXPRESS OF DRUG SCREENS AND RADIOGRAPHS BEING FORWARDED.
WHO WILL WE NEED TO CONSULT
WITH REGARDING THE FINDING OF THIS EXAM?______
_______________________________ PHONE NUMBER: _________________________
IF YOU HAVE ANY PARTICULAR
CONCERNS REGARDING THIS ANIMAL PLEASE MAKE THESE COMMENTS AT THIS TIME:
________________________________________________
______________________________________________________________________________
I, THE UNDERSIGNED, HEREBY REQUEST THAT ANGELA N. CHENAULT, D.V.M./LA PALOMA EQUINE
CLINC, PERFORM A PRE-PURCHASE EXAM ON _____________. THE SELLER OR PERSON
RESPONSIBLE FOR THIS HORSE’S CARE HAS STATED TO ME, THE BUYER, THAT THIS HORSE HAS / HAS NOT RECEIVED ANY MEDICATION WITHIN
THE LAST 14 DAYS. IF THE ANIMAL HAS RECEIVED MEDICATION WITHIN THE PAST
14 DAYS WHEN AND WHAT WAS ADMINISTERED?_________________
________________________________________________________________________________________
THE INFORMATION
PROVIDED BY THE VETERINARIAN IS NOT A WARRANTY, NOR IS IT INTENDED AS
SUCH. ANGELA N. CHENAULT, D.V.M./LA PALOMA EQUINE CLINIC HAS PERSMISSION TO
DISCUSS RESULTS OF PRE-PURCHASE EXAM WITH
SELLER AND/OR SELLER’S AGENT AND/OR ANY PARTIES
DIRECTLY INVOLVED. IF THE PURCHASER
REQUIRES A WARRANTY, OF REGAOR PROVING NON ADMINISTRATION OF DRUGS PRIOR TO
THIS EXAMINATION, EXACT HEIGHT AND WEIGHT, FREEDOM OF
VICES, PERFORMANCE ABILITY, ETC., HE/SHE SHOULD DO
SO FROM THE SELLER AS THESE MATTERS ARE NOT THE
RESPONSIBILITY OF THE VETERINARIAN. THE
BUYER SHALL BRING THEIR OWN TACK AND BE PREPARED TO
RIDE THE HORSE SO THAT IT MAY BE EXAMINED UNDER
SADDLE UNLESS THE HORSE IS NOT SUITABLE BROKE.
FLEXIONS WILL BE PERFORMED WITH A RIDER UP. IF AN AREA IS NOT AVAILABLE FOR A COMPLETE
EXAM ON SITE, THEN THE HORSE SHOULD BE BROUGHT TO THE CLINIC.
I HAVE READ AND UNDERSTAND THE
ABOVE INFORMATION AND HAVE ANSWERED ALL THE QUESTIONS TO
THE BEST OF MY KNOWLEDGE. IF THIS IS
SIGNED BY AN AGENT, YOU AGREE THAT THE BUYER IS AWARE OF THIS AGREEMENT.
__________________________________ _____________________
BUYER DATE
______________________________________ ____________________
BUYER’S AGENT DATE