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Fill out the online treatment agreement

To prepare for the appointment as well as possible, an online treatment agreement must be completed in advance. You can find this on this page.

Reception

+32 495 14 28 23

Clinic address

83 Avenue Beau Sejour, 1410 Waterloo

Opening hours

Monday - Friday (09.00 - 18.00)
Saturday - Sunday (Closed)

Customer form

HORSE INFORMATION

Name of horse

Alias / Nickname

Type

Sexe

Birth

Color

ID N° (Sire)

Chip N°

FEI Passport N°

Usage Usage

Responsible's name

Phone n° responsible

Insurance details (if applicable)

BILLING INFORMATION

Company legal name

Name of responsible

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 1

Name - location

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 location)

Name ( Delivery location if different )

Addres delivery

Paragraaf

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

Indien je een mens bent, laat dit veld leeg:.