Welcome!
Planning your first trip to Teva Veterinary Clinic? We know it can be tricky to hold your pet and fill out forms at the same time, so we have created an online hassle-free version for you to fill out in the comfort of your own home. We can't wait to meet you and your fur-child and welcome you to our Teva family!
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CLIENT INFORMATION
Surname *
Name *
Title
Address (residential) *
Phone number (home)
Phone number (work)
Cellphone number *
Email address *
ID number *
Employer
Spouse/family or friend cellphone number *
PATIENT INFORMATION
Pet's name *
Species *
Breed *
Colour *
Birth date or Approximate age *
Gender *
Required
Microchip number
Pet insurance policy (Name and plan)
PATIENT PRIMARY HEALTH CARE QUESTIONS
What diet is your pet on? (Please give the brand name)
When did your pet last receive a vaccination?
Has your pet been dewormed in the last 6 months?
Clear selection
Is your pet currently on tick & flea prevention ?
Clear selection
Previous veterinary clinic/s where your pet's records can be obtained?
Please list any prior illnesses, surgeries  or chronic condition that we should be aware of.
Is your pet on any medication or special diet at the moment?
Has your pet ever had an allergic reaction to a drug or vaccine before? (please specify )
PATIENT EMOTIONAL WELLNESS
Your pet's emotional comfort is of utmost importance to us at Teva. If you identify with any of the following below, we are here to help. One of our staff will be in contact with you to help discuss ways in which we can make both your and your pet's experience as stress free as possible.
Please select if any are applicable to your pet
PAYMENT AGREEMENT
WE DO NOT RUN ACCOUNTS. ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We will gladly prepare a written cost estimate if you desire (please ask the veterinarian).In cases of extensive medical or surgical treatment where full payment may be difficult on discharge, we accept all major credit cards and can establish a payment arrangement IF ARRANGED AND APPROVED IN ADVANCE of treatment.  

1. I acknowledge that all accounts are payable in full upon presentation.
2. I undertake to pay a deposit equal to the pre-estimated account prior to hospitalisation, and accept that such deposit is an absolute pre-condition for hospitalisation. I will settle any outstanding balance upon presentation of the invoice.
3. I undertake to inquire as to the extent and approximate costs of a proposed treatment, failing which I unconditionally accept that I am liable for the costs thereof.
4. I hereby render myself responsible for all costs, including interest at a rate of 2.5 % per month, for all telephone calls and time spent by the staff of this facility incurred in the recovery of the outstanding amount from time of presentation of the account.
5. In the event that an account is handed over to your lawyers or other agent for collection, I irrevocably agree to pay for all costs on a lawyer and client scale, Legal Counsel on their agreed scale, collection commission, (including the costs and collection commission of any correspondent Attorney employed by your Attorneys or agent in connection therewith) and interest thereon at the rate of 1 % per month.
6. I irrevocably consent to an attachment order being issued on my income against my current or future employers.
7. I irrevocably consent to the jurisdiction of the court of choice of this facility and agree that all performance took place within the jurisdiction of these courts.
8. I acknowledge that I have read these conditions and hold myself bound thereto.
9. I hereby choose the residential address listed above for the service of all notices and court documents.

I agree to the payment terms as set out above *
Required
GENERAL AGREEMENT
 
1. I hereby certify that I am the legal owner of all the pets that are listed under my file at this facility and that I am liable for all expenses incurred on their behalf at this facility.
2. I undertake to ensure that an adult person presents all pets for treatment, and am aware that the staff at this facility will not be held liable for any instructions for treatment from anyone under 18 yrs of age.
3. When leaving my pets in the care of others (holiday, overseas, hospital etc) I will make provision for a responsible adult person to act on my behalf,
3.1. Giving them express consent to contract with this facility on my behalf regarding treatments, finances, decisions regarding euthanasia etc
3.2. Enabling them to pay deposits and other payments on my behalf.
Should I fail to make such arrangements, I hereby unconditionally undertake to abide by the decisions made in good faith in my absence by the staff at this facility, and declare myself unconditionally responsible for the payment of all professional fees for such treatment.
4. I hereby unconditionally indemnify this facility and the staff of this facility against any claim of whatsoever nature arising from negligence in any form whatsoever.

I agree to the general terms as set out above *
Required
PRIVACY POLICY
1. I hereby understand that by completing this form, I agree to my personal information being collected and securely stored.
2. I hereby agree to receiving reminders and communications relating directly to my pet/s health needs. I acknowledge that I can request to be removed from these communications at any time by emailing info@tevavetclinic.co.za, marked for attention: POPIA Information Officer.
I agree to the privacy policy as set out above *
Required
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