LeadUS Mentoring Program 2015-16

The Sydney University Veterinary Teaching Hospital is acclaimed internationally for its exceptional health, care and welfare of animals. It is a general practice veterinary clinic, a referral centre for other vets to send complex cases and a teaching hospital for veterinary science students to learn the practical components of the veterinary profession.

We look forward to seeing you and your pet soon!

Client Information
Full Name*

PrefixFirst NameLast Name
Mobile Number*
Secondary Contact

PrefixFirst NameLast Name
Secondary Phone

Area CodePhone Number
E-mail*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred method of contact*

PhoneEmail

Pet Information
What is your pets name?*
What is {petName}'s breed?*
What is {petName}'s age?*
How long have you owned {petName}?*
What is {petName}'s sex?*
Is {petName} desexed?*
Has {petName} ever had a litter of puppies?*

YesNoUnsure

Usual Veterinarian & Referral Details
Is the UVTHS Primary Care team your usual vet?*

YESNO
Clinic Name*
Vet Name
Were you*

Referred by a veterinarianReferred by FriendsSocial MediaOther
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Owner Declaration and Agreement
By signing below or by authorizing treatment to the animal named above:
- I declare that I am over 18 years of age;
- I represent that I am the owner of the animal or that I am authorised by the owner to authorise treatment to the animal and accept this agreement on the owner’s behalf;
- I agree to pay all outstanding fees due on completion of consultation or treatment or on discharge of the animal from hospital. Please note that we do not accept ‘Diners Club’ or personal cheques;
- I understand and agree that all medical records and diagnostic images (e.g. radiographs) generated on my behalf by the University Veterinary Teaching Hospital Sydney (UVTHS) remain the property of UVTHS.;
- I consent to allow any data, images or samples obtained as part of the examinations or treatments at UVTHS to be provided to my referring veterinarian(s) and to be retained and used by UVTHS and the Sydney School of Veterinary Science for educational and research purposes provided confidentiality is assured;
- I consent for UVTHS staff to obtain my pets medical records from any other veterinarian or veterinary clinic if required; and
- I have read and understood these terms and conditions and accept that they form a legally binding agreement with UVTHS.
We may use photos of your pet on our social medial sites for promotional and marketing purposes.

Please tick this box if you do not consent to the use of your pet’s image.Please tick this box if you do not wish to join our mailing list.
Privacy Statement
We collect and use personal information in accordance with our Privacy Policy. We may share your personal information with other University of Sydney entities and with third parties that assist us with management and administration of our hospital including mailing, billing, delivery and technology services. More information about the handling of personal information and a copy of our Privacy Policy can be found here
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