New Client Information

Please fill in the information below to enable us to make your first visit as easy as we can.

Your details:

Title

First Name *

Last Name *

Address *

City *

Post Code *

Email *

Mobile Phone 1 *

Mobile Phone 2

Home Phone

Work Phone

Your Pet's details:

Pet Name *

Breed *

Colour *

Birth date (approx.) *

Date Last Vaccinated

Date Last Wormed

Date & Type of Last Heartworm Prevention

Insurance Company Name and Policy Number

How did you hear about us?

If you have been recommended to us by someone can you please tell us who so we can say thank you.

If you answered Other above please let us know where

Privacy Notice: South Yarra Vet Centre collects information to provide veterinary services to you. This information may also be for direct marketing of our services and products to you. Your contact information may be disclosed to our mailing house for the delivery of publications and reminders from us. A copy of our privacy policy is available upon request. *

Insurance - If your pet has or in the future does have insurance you hereby give us permission to send information to an insurance company to facilitate any insurance claims for your pet. If you do not wish us to send information to the insurance company please let us know in writing. *

Accounts - Payments of accounts must be made in full at the time they are incurred. A monthly account fee may be added to any unpaid accounts. In the event where an overdue account is referred to a collection agency and/or solicitors, you will be liable for all legal costs on the indemnity basis, whether incurred by us or by the collection agency and in the event where the collection agency charges commission, the commission which would be charged if it achieves 100% recovery shall be added to the debt and the total shall be treated as a liquidated debt. Accounts overdue by more than 30 days will be subject to interest prescribed by the Penalty Interest Rates Act (Vic) plus 2% from the date payment is due until the date payment is made. By clicking 'Submit' below you agree to these conditions. *

Welcome

New Client Information

Your details:

Your Pet's details:

How did you hear about us?