Client Registration and Preferences form

Title

Owner/Loanee (required)

Full name (required)

Address (required)

Postcode (required)

Tel Home (required)

Tel Mobile (required)

Tel Yard (required)

Your Email (required)

Invoicing address if different from above

About your horse(s)

Horse name
Registered name
Breed
Sex
Age
Colour
Height
Microchip Number
Known Allergies/Drug Reactions
Address where horse/pony is kept
Is horse/pony insured?
Type of Policy
Insurance Company
Policy Number
If horse is/has been recently registered with another veterinary practice please give details
Section IX signed?*
*It is a legal requirement to record the medicines administered to your horse. These records do not need to be kept if the horse is declared as NOT INTENDED FOR HUMAN CONSUMPTION by signing the appropriate part of SECTION IX in the passport. If the horse IS INTENDED HUMAN CONSUMPTION or SECTION IX is not signed, the passport must be presented at the time of treatment.

PRACTICE COMMUNICATION PREFERENCES

Please complete the following, to update, or for new clients to inform us, as to whether and how you would like to receive practice information - please read our Practice Privacy Policy for further details.

  1. BILLING PREFERENCES

    I prefer to receive invoices/reminders/statements by either
    EmailPost

  2. MARKETING PREFERENCES

    We would like to send you practice specific information such as newsletters/ client lecture invites/ practice offers/ equine healthcare information including disease outbreak notification/practice services that we feel may be of interest to you.
    I CONSENT TO RECEIVING PRACTICE SPECIFIC INFORMATION BY:
    EmailPostPhone*SMS Text*

    *this will be infrequent and will be, for example, - to check you have received the courtesy vaccination text reminder (if you haven't opted out of this service) if our text delivery reports tells us that it hasn’t been delivered to your phone; to make a personal invite to a client event;

    You may opt out of these services if you later change your mind. This can be done by email/ via our website “contact us” page /post/phone/text.

  3. COURTESY TEXT VACCINATION REMINDER SERVICE

    Kings Bounty Equine Practice provides a courtesy vaccination reminder service for clients once your horse has received a vaccination with us. (If we have not given your horse its last vaccination during the last 12 months, your vaccination reminders will automatically stop in any case. It still remains your responsibility to ensure that your horse is vaccinated on time as per our T&Cs).

    Limited non identifying information only will be passed on to a third party appointed by Boehringer Ingelheim for this purpose only.
    I would like to OPT OUT

    You may also opt out of this service by email/ via our website ”contact us” page /post/responding to “opt out” on the text message itself.

PLEASE NOTE THAT BY SIGNING THIS FORM AS THE OWNER OR LOANEE* OF THE HORSE, THAT YOU AGREE

  1. THAT THE PERSON RESPONSIBLE FOR THE CARE OF THE HORSE, IF APPLICABLE, HAS YOUR PERMISSION TO REQUEST VETERINARY ADVICE /ATTENDANCE/ INVESTIGATION/ TREATMENT. YOU, AS THE OWNER/LOANEE, WILL BE RESPONSIBLE FOR ALL COSTS INCURRED.
  2. THAT, IF YOU ARE THE LOANEE, THAT YOU ALSO HAVE PERMISSION FROM THE LEGAL OWNER TO AUTHORISE VETERINARY ADVICE/ATTENDANCE/INVESTIGATION/TREATMENT AS ABOVE.

BY TICKING THIS BOX I CONFIRM THAT I AM OVER 18 YEARS OF AGE AND HAVE READ, UNDERSTOOD AND ACCEPT THE TERMS AND CONDITIONS AS STATED ABOVE AND ON THE TERMS AND CONDITIONS HERE.

TODAY'S DATE(dd/mm/yyyy):

 

Please enter the code below to prove you are human!
captcha