Buyer Disclosure Form This completed form is required by law in order for us to provide service. This information is kept secure, private and will not be shared with any 3rd party without your expressed consent. Buyer Name* First Last Buyer Physical Address* 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 Buyer Mailing Address (if different, otherwise leave blank) 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 Buyer Mobile Phone Number*Buyer Email* Section BreakIs there an agent or representative to communicate with before, during or after the exam?* Yes No How would you like us to communicate with your agent or representative?* Communicate with representative before, during and after the exam. Communicate with representative during and after the exam. Communicate with representative only after the exam. Communicate with representative only after instruction to do so. Your agent or representative must be available during the times to contact otherwise attempts to contact with no answer will delay the exam and potentially increase exam cost.Agent or Representative Name* First Last Agent or Representative Mobile Phone Number*Agent or Representative Email* Section BreakOwner/Seller Name* First Last Registered name of the horse (N/A if not available)* First Barn name of the horse (N/A if not available)* First Breed (please fill in)* Sex (please choose one)*GeldingMareStallionColor and Markings* Please list basics, with notes on markings if you know them. For example, Bay with star, right front pastern white. Please note brands if present. Animal's Date of Birth* DD slash MM slash YYYY Intended use* Please note or list all intended uses of the horse standing for the purchase exam, in order of importance.Comment Section*Please note special circumstances, requests, concerns or any issue you wish to convey regarding the horse, the exam or circumstances. Please type "NONE" if you have no comment or concerns. Laboratory Testing or Procedures Requested* All testing is DECLINED Blood Chemistrty and Complete Blood Count Drug Screen for Anti-Inflammitory Drugs (eg. Phenylbutazone and Banamine) Drug Screen for Anti-Inflammitory Drugs and Steriods (as above plus, eg. Depomedrol and Triamcinolone) Drug Screen for Anti-Inflammitory Drugs, Steriods and Sedatives (as above plus, eg. Acepromazine, Fluphenazine) Fecal Parasite Test Coggins (Equine Infectious Anemia test - usually for transport) Health Certificate (for transport out of state) Airway Endoscopy Gastric Endoscopy Reproductive Evaluation Other (please note or list below in "comments") Please tick the box for each item of interest. This is NOT a commitment or contract for services, but an indication for us to discuss those items with you in more detail. Imaging Requested* Imaging is DECLINED Radiography - Front Feet (4 views each) Radiography - Front Feet/Navicular (6 views each) Radiography - Fetlocks Front (4 views each) Radiography - Knees (carpus) (4 views each) Radiography - Fetlocks Hind (4 views each) Radiography - Hocks (4 views each) Radiography - Stifles (3 views each) Radiography - Neck (4 views) Radiography - Back (4 views) Radiography - Other Images are to be reviewed by a board certified radiologist Ultrasonography - one site/region Ultrasonography - two sites/regions Please tick the box for each area of interest for imaging. This is NOT a commitment or contract for services, but an indication for us to discuss in more detail. Cost is up to 60.00 per image plus 57.00 PACS/Archiving Fee and 50.00 sedation fee. Ultrasonography is approximately 280.00 per site plus 50.00 sedation fee.I will be present for the exam* Yes No - without representation No - with representation If answered "No - without representation", please enter "NOBODY". If "No - with representation", please list who will be present on your behalf.* Statement of age for legally binding engagement* I am 18 yrs of age or older.Consent and Acknowledgement* I acknowledge this statement, agree and provide my consent.This purchase examination provides information about the horse’s health and condition at the time of the examination. It is the buyer’s responsibility to inform the veterinarian of the extent of examination and the selection of any diagnostic tests chosen. The examination is not to be used as a prognosis for future use, and findings are not a warranty, express or implied, of future health, soundness or suitability. The veterinarian’s role in the examination is not to pass or fail the horse, but to help the prospective buyer make an informed decision considering the horse’s overall health and soundness at the time of the examination. The decision on whether or not to purchase the horse examined is solely the buyer’s choice and responsibility. The buyer should understand that there are limitations to a purchase examination, and certain conditions may not be detectable by clinical, radiographic, ultrasonographic and/or laboratory examinations on the day of the examination. The buyer acknowledges that the veterinarian is not liable for conditions that may present in the future that could affect performance or resale, and this agreement is to release, waive, discharge and dismiss Rogue Equine Hospital and all employees from any claims arising directly or indirectly from the performance of the purchase examination. The information and findings from today’s exam may be shared with the current owner/agent of the horse.Cancellation Fees - Agreement* I agree to the following cancellation fees.In the event of a scheduled and confirmed appointment being cancelled for ANY REASON within 24 hours of the scheduled appointment, a cancellation fee may apply. Cancellation Fee within 12 hours, or same day is $250.00, cancellation notification 12-24 hours is $100.00. Credit Card Deposit* I agree to provide a valid credit card on file for deposit to be held to be applied toward cancellation fees or services provided relative to a purchase exam.A credit card is required to be on file, and a deposit of $250.00 to be collected/charged upon booking, for the purpose of cancellation fees (see above) or to apply toward services rendered relative to a purchase exam. A final cost will be provided at conclusion of the exam and your card will be charged for the balance unless other arrangements have been made. Your agreement for the deposit and final balance to charged to the provided card is required to hold a scheduled appointment dedicated to your service request. Please call our office after completing this form to process your card. Signature of Buyer/Person Responsible*This form must be completed and signed by the person ordering the purchase examination and who is financially responsible for this service. CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
