Registration

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Client

Fields marked with * are mandatory. All other fields are optional and do not need to be filled in.

I am a corporate client / association / farmer.

Company / Association*

Viehverkehrsverordnung no. (HIT no.)

Disease fund no.

Mrs* Mr* Mx*

Dr. Prof. Dr.

First name*

Surname*

Street*

House no.*

Postal code*

City*

E-mail address

Date of birth (DD.MM.YYYY)

I would like to enter an additional address.

Street

House no.

Postal code

City

Please enter your telephone and mobile number separately with the country code (+49 for Germany) and the phone number.

Phone no.

Mobile no.

I want to receive invoices via e-mail.

Special notes:

Patient

Fields marked with * are mandatory. All other fields are optional and do not need to be filled in.

This patient carries a date of death or is marked as inactive – only patient name and species are required.

I would like to create a livestock.

Patient name*

Breed

Cross-breed

Livestock no.

Livestock size

Date of birth (DD.MM.YYYY)

Colour

Weight [kg]

Transponder no.

Passport no.

Breed registry no.

Life no. (for horses)

If an animal is not intended for food production, certain medicinal products may be used in its treatment that are not approved for food-producing animals. This broadens the therapeutic spectrum and allows for additional, medically appropriate treatment options to be used.

No food-providing animal Food-providing animal

By signing this declaration, I confirm that my rabbit is not intended for food production and will not be used for food production by me. I am aware that using the rabbit for the production of food constitutes a violation of the Food and Consumer Goods Act and may be prosecuted as a criminal offense.
(Based on the letter of the Federal Ministry of Health dated 17 February 1995 (Ref. No. 425-7210) regarding the animal owner’s declaration for horses.)
In the event that the rabbit is sold or transferred, I undertake to inform the new owner of this declaration, in particular of the fact that, for medicinal and food-law reasons, the rabbit may not be used for food production.
This declaration is valid indefinitely.

Pet insurance

Insurance no.

Please note that you may have to pay bills to a pet insurance company first.

Feeding (type of food, additives, treats, food changes and other information)

Long-term medication

add drug

Former diagnoses

add diagnosis

Documents / pictures

upload document / picture

Special notes about this patient:

next add additional patient

GDPR consent / Treatment contract

GDPR consent

For the proper medical treatment of your animals and the billing thereof, it is necessary to store certain personal data. We therefore ask for your consent as set out below.

As the animal owner, I hereby consent to the veterinary practice storing and using the following data for the purpose of providing the best possible care:

• my address,
• my contact details (e.g. telephone number, email address),
• data relating to the treatment of my animals, and
• records of curative treatments and administered medications.

I consent to my data being disclosed, where necessary, to:

• external laboratories,
• external service providers required for billing purposes (e.g. billing or clearing agencies),
• pet registries (e.g. TASSO),
• other veterinary practices in the event of a referral, and
• external service providers for the purpose of communication with the practice.

Beyond this, any disclosure of data to third parties shall only take place within the scope permitted by law and, where applicable, only with my renewed consent.

I further consent to:

• being informed by the practice about upcoming vaccinations for my animals, and
• receiving current information from the practice.

I may request information at any time about the scope of the data stored.
I have been informed that this declaration is given voluntarily and that I may revoke it at any time. In this case, any data already collected will be deleted.

Treatment contract

I hereby confirm that I am the owner of the animal and am therefore entitled to enter into a contract for the performance of necessary treatments and surgical procedures. I further confirm that I am willing and financially able to bear the costs arising therefrom. In this context, I declare that, at the time of making this declaration, I am not subject to any court-ordered debt or insolvency proceedings.

If I am not the owner of the animal, I confirm that I am acting on the express instructions of the animal’s owner. In the absence of such authorization, or if the owner disputes the existence of such authorization, I hereby confirm that I will personally bear the costs incurred as a result of the treatment.

To the extent necessary for diagnostic purposes, I authorize you to engage third-party services (such as laboratory examinations or similar services) in my name and at my expense.

I hereby confirm the accuracy of the information provided and commission you to examine and/or treat my animal, assuring you that I am authorized to do so. I acknowledge that, following the examination of my animal, I am required to settle the incurred treatment costs in cash, by debit card (EC card), or by credit card. Any follow-up treatments shall likewise be subject to this contract.

By signing this document, I agree to the treatment contract and to the data protection consent declaration described above, within the scope of its stated purpose.

I don't want to receive newsletters.
I don't want to receive appointment reminders.
I don't want to receive vaccination reminders.

I hereby confirm that I am 18 years of age or older.

Please sign in the following field:

City

Date

If you would like to receive a copy of the GDPR consent and the treatment contract, please enter your e-mail address in the following field:

E-mail address

Spam protection: Please mark the cow and the flamingo:

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