Howard Springs Veterinary Clinic
Lot 43 Smyth Road
PO Box 1020 Howard Springs NT 0835
Ph 08 89831458 all hrs
Fax 08 89831750
New Client / Patient Details
Your Details
Name:
Mr / Mrs / Ms / Miss _____________________________________________________________
Postal Address
___________________________________
Home Address
______________________________________
___________________________________
______________________________________
Email Address:
Phone: Home _______________________ Work __________________ Mobile _____________________
Your Pets’ Details
Pet 1
Pet 2
Pet 3
Name
Name
Name
Breed
Breed
Breed
Colour
Colour
Colour
Sex
Sex
Sex
Age/DOB
Age/DOB
Age/DOB
Desexed Y / N
Desexed Y / N
Desexed Y / N
Microchipped
Microchipped
Microchipped
Y / N
Y / N
Y / N
.
Please read the following and sign below
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I agree to pay the account in full at the time of discharge of the animal from hospital
I confirm that to the best of my knowledge the above details are correct.
I am authorised to present this animal for treatment
I understand that if I have not contacted the clinic within 48 hours of being asked to do so, or have not collected my animal
within 48 hours of being advised to do so, the animal will be regarded as abandoned and its future will be decided by the
senior veterinarian. Options will include re-homing, RSPCA or euthanasia. I understand I will be responsible for all costs of
treatment and hospitalisation even if I do not collect the animal from the clinic.
I agree to indemnify Howard Springs Vet Surgery and/or any staff member in the event of loss or liability that may arise
during the treatment of my animal.
I understand that account keeping fees will be charged to my account on a fortnightly basis if I am in arrears at any time and I
agree to pay those account keeping fees that may accrue on my account.
I agree to indemnify Howard Springs Veterinary Clinic of any expenses, costs or disbursements incurred in recovering any
amount owed by the customer including debt collection agency fees and legal costs which shall be paid by the customer,
provided that those fees do not exceed the scale charges as charged by the debt collection agency or legal representative.
Signed___________________________________________
Date ______________________