Vendors - Signup Form - Fourways Equine Clinic

Welcome to Fourways Equine Clinic.

We look forward to a long and mutually beneficial relationship.

This is just a short letter to explain “who and what we are”.

Fourways Equine Clinic is a 100% equine practice operating in the greater Johannesburg area.

We pride ourselves on our excellent service, whether it be in an ambulatory mode or a high tech hospital mode. We are capable of assisting you in all your related equine problems.

Although our office hours are from 07h00 to 17h00, Monday to Friday, we will always be contactable after hours on 082 459 0129 for emergencies.

We are based at:

96 Poplar Road
Blue Hills
Kyalami
1684

Fourways Equine Clinic has many different veterinarians speciliaising in different areas. In the interests of brevity, they cannot all be listed here, but in time, I am sure you will get to know us all. To facilitate all communications at this stage, all queries can be addressed to sandy@fourwaysequine.co.za.

To help create a good relationship please could we ask you to fill in the following particulars so that we can create you as a vendor on our system:
DETAILS OF VENDOR
Vendor / Agent's Name:*
Prefix First Last
Date
Phone Number*
Mobile
Email Address*

Horse's Name
How long have you been acquainted with this horse?
Is the horse in full work at the moment?
Yes
No
If not,why?

Do you have any knowledge off the following, past or present:
Disease*
Yes
No
Lameness*
Yes
No
Accidents*
Yes
No
Vices*
Yes
No
Any abnormalities of wind or breathing?*
Yes
No
Medication within the last 45 days(excl routine dewormer)?*
Yes
No
Dental disease*
Yes
No
If Yes to any of the above, please specify details

For what purpose is the horse being assessed?*
Declaration: I consent to a veterinary examination on the above horse by Fourways Equine Clinic. I understand that this examination may include:*
Physical examination
Blood/Urine collection and testing
Radiographs
Upper airway endoscopy
Internal Examination by ultrasound or palpitation
Other examinations as discussed
Terms and Conditions*
I understand that each examination carries a finite risk.I will arrange transportation at my risk to a suitable examination facility if required. I accept that the information gained in the course of this examination is the property of the person commissioning the examination.

Vendor/Agent
Date

Vendors - Signup Form

Vendor's Statement

Step 1 of 5

DETAILS OF VENDOR

Do you have any knowledge off the following, past or present: