Make an appointment

Home » Make an appointment

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.

Online treatment agreement

Client / owner / company

Company name

Salutation

First name

Last name

Street name + house number

Zip code

City

Country

Telephone number

E-mail address

VAT numbers

Social security number

Authorized supervisor

Mr. / Mrs. / Legal entity name

(Mobile) phone

Referring veterinarian / physiotherapist / dentist / farrier

Name of referrer

Horse

Name of the horse

Date of birth horse

Dropdown

Transponder number

General

I have already made an appointment

Ja, vul de datum en tijd in bij de volgende vraag

Nee

Date and time appointment

Place of the appointment

Op de kliniek bij Via Nova

Op locatie / aan huis

I am already a customer of Via Nova

Nee, nieuwe klant

Comments

Signature

Ik ben bevoegd deze (behandel)overeenkomst te ondertekenen.

General terms and conditions

Ik heb de Algemene Voorwaarden en Addendum gelezen en ga hiermee akkoord.

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

If you are human, leave this field blank.