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):

     

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