Registration form for appointments »pre-arranged by telephone«!

Contacts for arranging appointments

Bitte lasse dieses Feld leer.Bitte lasse dieses Feld leer.

Information about the owner

Title*

First name*

Last name*

Street*

Nr.

Postcode*

City*

Country*

Please enter relevant country*

Phone/Mobile*

Email*

Location of the agreed appointment?* »Link to overview/date cooperation practices

Date of the agreed appointment?* (tt.mm.yyyy)

Which payment method do you prefer?*
»In Switzerland and for clients from Austria, payments are only accepted in cash in Euros or via card

Date of birth if payments via BFS* (tt.mm.yyyy)

Do you have pet health insurance?*

Which insurance?*

Contract type?*

Insurance number?*

Since when?* (tt.mm.yyyy)

Transfer back to the house veterinary practice?

I want a referral back to my house veterinary practice*

If you wish to be referred back – Who is your referring veterinarian?

Practice*

Email veterinary practice*

Street*

No.*

Postcode*

City*

Information about your pet

Are you the owner?*

Species*

Breed*

Name*

Sex*

Date of birth/Age* (tt.mm.yyyy)

Weight in kg*

Neutered*

Date vaccination* (tt.mm.yyyy)

Color*

Chip no.

I am a commercial pet owner*

Animal is used for food production*

Pre-existing conditions or long-term medication?*

Describe pre-existing conditions or long-term medication*

I would like to send pictures/data*

Send your data / pictures (jpg, png, pdf, docx, zip up to max. 3 MB)

Please send DICOM-images solely via WeTransfer.com

Upload 1

Upload 2

Upload 3

Upload 4

»Send large files via wetransfer.com to praxis@tierarzt-rosin.de with your first and last name in the message

General

How did you find out about our practice?

Other remarks

Spam protection*: How much is 3 x 3 ? (Enter result below)

I have read the AGB (in german) and I accept the terms!*
I have read the Privacy Policy Note (german)!*

The binding treatment or service contract is only realized when the appointment is observed on site in our practice. We kindly ask you to cancel the appointment in good time if you do not want to keep the appointment.