BOOK AN APPOINTMENT

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Complete our customer form

To book your appointment, please complete in advance this form and do not forget to precise the problem of your horse.

Reception

+32 495 14 28 23

Clinic address

Avenue Beau Séjour, 83
1410 Waterloo

Opening hours

Monday - Friday:
09.00 - 17.00

Customer form

HORSE INFORMATION

Name of your horse

Alias / Nickname

Type

Sexe

Birth date

Color

ID N° (Sire)

Chip N°

FEI Passport N°

Usage Usage

Responsible's name

Responsible's phone number

Insurance details (if applicable)

BILLING INFORMATION

Company legal name

Responsible's name

Address

Address Line 1 (required)

Address Line 2

City (required)

State / region

Postal Code (required)

Country

VAT N° (if applicable)

Phone number

E-mail

Preferred payment method

HORSE LOCATION

Stable's name

Address

Address Line 1 (required)

Address Line 2

City (required)

State / region

Postal Code (required)

Country

Phone number

E-mail

Period

DELIVERY ADDRESS: FOR MEDICATION AND MATERIAL (if different from horse's location)

Name

Addres delivery

E-mail

Phone

VET'S CONSULTATION

Reason

veterinary

Remarks

Referred by

Appointment date and time

Appointment place

Guidelines

Acceptance

I am authorised to sign this (treatment) agreement .

I have read and accepted the general Terms and Conditions and appendix

If you are human, leave this field blank.