Pre-Purchase Exam Form

Please complete the following:

To be completed by potential buyer

"*" indicates required fields

Name*

First Last

Email*

Phone*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Seller's Name*

First Last

Seller's Phone Number*

Barn Address (where exam will take place)*

Street Address Address Line 2 City State ZIP Code

Registered/Show Name*

Barn Name*

Gender*

Mare

Gelding

Stallion

Horse's Birthday or Age*

Horse's Breed*

Horse's Color*

Intended Use of Horse

Have you met/tried the horse?*

Yes

Will you be present at the exam?*

Yes

Will you be requesting radiographs (x-rays)?*

Yes

If yes, what views are you interested in?

Consent*

I, the undersigned, have read, understood, and agreed to the below information.

- I understand that in order to qualify for emergency services, I must be a current full service client.
- I authorize Lake Erie Equine LLC to provide care for my horse(s).
- I understand that payment is due at time of service.
- I authorize Lake Erie Equine LLC to contact me via sms/email about my service, appointments, billing, and other inquiries.

Signature*

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

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PO Box 512
Milan, Ohio 44846

Phone 419.577.7195

info@lakeerieequine.com

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Email Address*

Pre-Purchase Exam Form

Please complete the following:

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