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 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 ______________________