Equine Sports Medicine Practice - customer form

EQUINE SPORTS MEDICINE PRACTICE - CUSTOMER FORM

TERMS AND CONDITIONS

HORSE INFORMATION

NAME OF HORSE

( Horse Information )

ALIAS/ NICKNAME

TYPE

SEXE

BIRTH

BREED

COLOR

ID N° (SIRE)

CHIP N°

FEI PASSPORT N°

USAGE

RESPONSIBLE'S NAME

PHONE N° RESPONSIBLE

INSURANCE DETAILS (if applicable)

BILLING INFORMATION

COMPANY LEGAL NAME

Billing Info

NAME OF RESPONSIBLE

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

VAT N° (if applicable)

PHONE

Country

(###)

###

####

PREFERRED PAYMENT METHOD

HORSE LOCATION 1

NAME - LOCATION

Horse Location

ADDRESS - LOCATION

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PHONE

Country

(###)

###

####

PERIOD

DELIVERY ADDRESS FOR MEDICATION AND MATERIAL( IF DIFFERENT FROM LOCATION )

NAME

( Delivery location if different )

ADDRESS DELIVERY

PHONE

(###)

###

####

VET'S CONSULTATION

REASON

VETERINARY

REMARKS

REFERRED BY

APPOINTMENT DATE AND TIME

APPOINTMENT PLACE

GUIDELINES

I am authorised to sign this (treatment) agreement .

I have read and accepted the general Terms and Conditions and appendix ( please see above for T&C's)

TERMS AND CONDITIONS

Ambulatory equine veterinary service specialised in internal and sports medicine

DR EMMANUELLE VAN ERCK – WESTERGREN

ESMP - Equine Sports Medicine Practice
Avenue Beau Séjour, 83 1410 Waterloo (Belgium)
Tél. : +32 497 24 86 84
evanerck@esmp.be

DR FE TER WOORT

ESMP – Equine Sports Medicine Practice
Avenue Beau Séjour, 83 1410 Waterloo (Belgium)
Tél. : +32 494 26 23 13
fterwoort@esmp.be

DR VIOLAINE PINEAU

ESMP – Equine Sports Medicine Practice
Avenue Beau Séjour, 83 1410 Waterloo (Belgium)
Tél. : +32 492 26 85 69
vpineau@esmp.be

https://altano-group.whistleblowing-software.com/