Client Details and Consent Form
Title: Miss/Mrs/Ms/Mr/Other
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Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
County
Postal Code
Mobile Phone Number
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Phone Number
Work Phone Number
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Email Address
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Name of Employer
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Names all persons who can have access to or can make decisions regarding the treatment of your animals needs and any financial information including outstanding payments.
Name Of Authorised Contact
First Name
Last Name
Phone Number of Authorised Contact
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Horses Details
Name
Sex
Microchip
Breed
Colour
DOB
Yard Address
Insurance Company
Names of all veterinary practices previously or concurrently registered with. This information is a legal requirement following the new RCVS guidelines as of September 1st, 2023.
Type a question
I am happy for Cliffe Equine Vets to request the clinical history from my previous vets
2nd Horse Details
Name
Sex
Microchip
Breed
Colour
DOB
Insurance Company
Name of veterinary practice previously registered with
Type a question
I am happy for Cliffe Equine Vets to request the clinical history from my previous vets
3rd Horse Details
Name
Sex
Microchip
Breed
Colour
DOB
Insurance Company
Name of veterinary practice previously registered with
Type a question
I am happy for Cliffe Equine Vets to request the clinical history from my previous vets
4th Horse Details
Name
Sex
Microchip
Breed
Colour
DOB
Insurance Company
Name of veterinary practice previously registered with
Type a question
I am happy for Cliffe Equine Vets to request the clinical history from my previous vets
5th Horse Details
Name
Sex
Microchip
Breed
Colour
DOB
Insurance Company
Name of veterinary practice previously registered with
Type a question
I am happy for Cliffe Equine Vets to request the clinical history from my previous vets
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Next
GDPR - Are you happy to receive vaccination reminders, dentistry reminders, occasional newsletters, special offers and information by phone, email, text and post? Please note you will only receive information directly from Cliffe Equine Vets and we will not share your details
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Yes
No
Please read the following terms of business carefully
Please list other Veterinary Surgeons below:
I have read and agree to the terms of business and the mutual client agreement.
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Date
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Month
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Day
Year
Date
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