Telephone Consult Request Form
Is This Request Urgent?:   Yes    No
Personal & Contact Details - To be completed by person of legal age.
Title: Mr   Mrs   Ms    Miss   Dr   Mr & Mrs
Last Name:
First Name(s):
Phone Work: Phone Home:
Mobile: Fax Number:
Email:
Physical Address:
Postal Code:
Current Vet:
Animals Details
Animals Name:
Species:
Breed:
Crossed With?:
Colour:
Gender: Male Female
De-Sexed? Yes No
Microchip No:
Animals Age:
Reason For Consultation
Do you have a: Super Gold Card  Yes No
Please indicate how you came to hear about us
Friends Name: If via friend:
Specify: If other:
Communication Preferences
In order to assist us to communicate effectively with you, please indicate your preferred means of communication for each of the following:
Mail E-Mail Phone
Appointment Confirmation
Special Offers | Promotions | Newsletter
Reminders (Vaccinations, dentals, etc.)
Statements
Declaration

I, being the owner / authorized agent of the owner (select one) of the above animal(s), consent to diagnostic and therapeutic procedures to be performed on my animal(s) by Holistic Vets.

I understand and accept that :

  • All options will be thoroughly discussed and explained to me to my satisfaction. If something is not clear, I will ask for further clarification.

  • I may elect the options that would be most suitable within the health and welfare needs of my pet.

  • The monitoring of my pet’s health during treatment is of vital importance and I accept the responsibility of ensuring follow up consultation should my pet’s condition not improve or further deteriorate.

  • Accounts are payable at the time of treatment. Outstanding accounts are subject to an interest charge of 2.4% per annum, account fees of $5.00 per statement sent, and I am liable for any cost incurred in the collection of overdue accounts.

If presented by an agent: I warrant that I am authorized to act on behalf of the owner as agent in respect of the above animal.

Important Note: Please enter your full name below. In so doing, you agree to and accept that this entry is equivalent to you signing a printed document and therefore acknowledge that all information provided above is accurate and you accept all terms and conditions and that you are of legal age to do so.

Full Name:
Todays Date: / / (dd/mm/yyyy)
I have completely and fully read this document and agree to its terms.