REVS New Client Consent Form

New Client Consent Form

Please complete before our visit with you.
NAME*

First NameLast Name
Patient's name *
Your horse's name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this your horse's address?*

YESNO
Horse's Address

Property/ Agistment Name

Street Address

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please type your phone number here.
Declaration

I undertake to pay all costs incurred in this procedure. I agree to your trading terms of payment at the time of discharge (unless other terms have been arranged prior to surgery). If a delayed payment plan is negotiated, I agree to pay all outstanding costs associated with any account within 7 days. I agree that I will be liable for all costs associated with the recovery of any outstanding invoices. Such costs may include an overdue account fee, all Debt Collection at the agreed rate of 28% plus GST, and Legal Costs at the rate charged by the Legal Practitioner or Court.

I agree to indemnify the attending veterinarian, their servants and agents for any loss or liability that they may incur as a result of any inaccurate information provided on this consent form, whether intended or otherwise.
I am the owner of the above named patientThe owner of the above named patient is:
and I am authorised by said owner to present the patient for surgery as detailed above. (If signed by an agent of the owner, the agent warrants that he/she has fully authority from the owner to provide the consent and the information contained in this Consent Form.)

If the animal is insured, I have informed and gained consent from the above animal’s insurance policy provider to present it for surgery as detailed above.
Signature*

Clear
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