NEW CLIENT REGISTRATION

NEW CLIENT REGISTRATION
Date *

DayMonthYear
Date
Title*
Name*

Full NameSurname
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postal Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ID Number *
ID Copy*

Cancelof
Cell number 1 *
Cell number 2
Email 1 *
example@example.com
Email 2
example@example.com
Signature *

Clear
INDEMNITY & CONSENT

I hereby consent to and authorize this veterinary surgeon, and his/her practice to share my personal and account payment information and history with any third party. I understand and acknowledge that treatment may be refused due to non-payment. The refusal of treatment due to the non-payment of accounts will include, but will not be limited to, the refusal of administering any emergency and/or after- hours treatment required by my animal. I unconditionally indemnify Underberg Veterinary Surgery and its staff/volunteers against any loss, liability, or damage of whatsoever nature (whether direct, indirect, or consequential) that may result from the sharing of/accessing of my account information in this regard, including but not limited to the death of my animal due to the refusal of any veterinarian from treating the animal because of my negative account history (if applicable I understand that this practice operates on a cash-only basis, no other sales will be done if I have an outstanding account, furthermore that the relevant administration fees will be charged.

POPIA COMPLIANT

Disclaimer: Underberg Veterinary Surgery will not sell, trade, barter, or distribute the information with any third party, except in case of non-payment or regards to the treatment of the animal.
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