Make an appointment

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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.

We will contact you within 2 working days for an appointment.

Online treatment agreement

Make an appointment

Client / owner / company

Company

Salutation *

First name *

Last name *

Address *

Zip code *

City *

Country

Telephone number *

E-mail address *

VAT numbers

Social security number

Owner's representative

Mr. / Mrs. / Legal entity name

(Mobile) phone

Referring Veterinarian / Physiotherapist / Dentist / Farrier

Company name

Name

Horse

Name horse *

Gender horse *

Date of birth horse

Transponder number *

General

I have already made an appointment:

Yes, please fill in the date and time in the next question

Date and time appointment:

Place of the appointment:

At the clinic at Via Nova

On location / at home

I am already a Via Nova customer.

Yes

No, I am a new customer

Comments

Authorizing *

I am authorized to sign this (treatment) agreement.

General terms and conditions *

I have read and accepted the general Terms and Conditions and Addendum.

May we remind you that the bill must be paid at front office immediately after the consultation and/or the treatment. This can be done with Bancontact/debit card (preferred), credit card (VISA/Mastercard) or cash. Please contact us if you are not present yourself and you would like to pay via a payment link when your horse goes home (= instant payment)

If you are human, leave this field blank.