Registration

Client

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

First name*
Surname*
Street*
House no.*
Postal code*
City*
E-mail address*
Date of birth (DD.MM.YYYY)*

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

Phone no.* (or enter a mobile no.)

Phone no.*

Mobile no.* (or enter a landline no.)

Mobile no.*
 

Special notes:

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Patient

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

Patient name*
Breed*
 
Date of birth (DD.MM.YYYY)*
Colour
Weight [kg]
Transponder no.
Breed registry no.
Life no. (for horses)

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

Former drugs

add drug

Documents / pictures

upload document / picture

Special notes about this patient:

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GDPR consent / Treatment contract

Treatment contract

I hereby confirm that I am the owner of the animals that I present to this practice and am therefore authorized to enter into a contract for the performance of necessary examinations, treatments, and surgical procedures. This declaration applies to all animals that I currently or in the future present or arrange to be presented to this practice. I further confirm that I am willing and able to bear the costs arising from such examinations and treatments. I also declare that, at the time of making this declaration, I am not subject to any judicial insolvency or debt proceedings. If I am not the owner of an animal presented, I confirm that I am acting with the express authorization of the animal’s owner. If such authorization is not present or if the owner disputes the existence of such authorization, I hereby confirm that I will personally be responsible for the costs arising from the treatment. To the extent necessary for diagnostic or treatment purposes, I authorize the practice to commission services from third parties (such as laboratory examinations) in my name and on my account.

I confirm that the information provided by me is accurate and I hereby instruct the practice to examine and/or treat the animals presented by me. I confirm that I am authorized to do so. Fees are charged according to the German veterinary fee schedule (GOT) plus travel costs and materials; for emergency services (at night, on weekends and public holidays) at least twice the standard rate applies. I pay directly after the appointment by card or cash, or settle the invoice within 14 days by bank transfer.

This declaration and the treatment contract established hereby apply to all animals that I present to this practice, including any follow-up treatments.

By signing, I agree to the treatment contract and to the presented data protection consent declaration within the scope of its intended purpose.

 
 
 
 
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 seal and the elephant:
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