Drs. Stef & Tom Cilliers
Newcastle Dierehospitaal
Newcastle Animal Hospital
Patersonstraat 115 / 115 Paterson street
Volle Naam:
Full Name:
Posbus:
P.O. Box:
Tel Huis:
Tel Home:
Sel Nr:
Cell No:
Street:
Straat:
ID No:
Diereartse
Veterinary Surgeons
www.nvh.co.za
BVSc (Pretoria)
Facebook: Newcastle Veterinary Hospital
Skype: Newcastle.vet.2
Tel Werk:
Tel Work:
Tel Eggenoot:
Tel Spouse:
Werksadress:
Work Address:
E-pos:
E-mail:
Pet Details: / Troeteldier Besonderhede:
Naam:
Name:
Geslag:
Sex:
Volgende Inenting:
Next Vaccination:
Ras:
Breed:
Geboortedatum:
Birth Date:
Kleur:
Colour:
Klagte:
Complaint:
I, the undersigned, an adult major, hereby authorize the veterinarian and staff of this
veterinary facility to perform any reasonable treatment/anaesthesia and surgery they
may deem necessary, including further or alternative measures as may be necessary
during the course of the surgery and/or treatment of my animal.
I undertake to keep in daily contact to enable the staff to inform me of the progress,
costs incurred, and additional treatment involved, of my hospitalized animal.
I recognize that there is some degree of risk attached to any medical or surgical
procedure or treatment. I have discussed any concerns I may have with the
veterinarian. I hereby absolve the veterinarians, staff and this facility from all actions
and liability, arising directly of indirectly from the treatment/anaesthetic/surgery.
I am aware that this veterinary facility does not provide 24-hour per day monitoring of
patients. Should I wish to have my pet monitored 24 hours per day while hospitalized,
I will make arrangements with the staff of this facility.
I the undersigned herewith undertake to pay upon my animal’s discharge for
professional serviced rendered on request by the undersigned in respect of any
animals presented by him/her for treatment according to the fees suggested by the
South African Veterinary Council. Fees list available on request. The undersigned
further undertakes to pay all Legal costs, collection commission and tracing fees on
an Attorney and Client basis should any costs be incurred in the collection of any,
monies due. The undersigned further undertakes to pay interest on overdue
amounts at interest rates as allowed by Law from time to time.
I acknowledge that I have read these instructions and hold myself bound thereto.
COST ESTIMATE: R_________________________
Handtekening:
Signature:
Naam Drukskrif:
Print Name:
Datum:
Date:
may vary due to unforeseen circumstances