Admission form - Tierarztpraxis Rosin

Admission form for agreed appointments

Read our information on:

Gold acupuncture procedure »Link, pdf
Taking care of your pet after the gold acupuncture procedure »Link, pdf
Anesthesia preparations for CT-/DVT-examinations »Link, pdf

*Required field

Information about the owner

Title*

First name*

Last name*

Street*

Nr.

Postcode*

City*

Country*

Phone/Mobile*

Email*

»Link to overview/date cooperation practices

Location of the agreed appointment?*

Date of the agreed appointment?*
Mac user enter the date as follows: yyyy-mm-dd (e.g. 2020-05-04)

For appointment in the following veterinary practices, please contact them directly:
- Cologne - Tierarztpraxis am Gotenring »Contact
- Marbach-Rielingshausen - Tierarztpraxis Dr. Ole Heinzelmann »Contact

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*
Mac user enter the date as follows: yyyy-mm-dd (e.g. 2020-05-04)

Do you have pet health insurance?*

Which insurance?*

Contract type?*

Insurance number?*

Since when?*
Mac user enter the date as follows: yyyy-mm-dd

(e.g. 2020-05-04)

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*

Street*

Nr.*

Postcode*

City*

Information about your pet

»Link to Terms and conditions

Are you the owner?*

Species and breed*

Name*

Date of birth*
Mac user enter the date as follows: yyyy-mm-dd (e.g. 2020-05-04)

Sex*

Weight in kg*

Neutered*

Color*

Chip-nr.

Pre-existing conditions (heart, liver, kidney, etc.)?*

If yes, please describe briefly*

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

Long-term medications?*

If yes, which medication 1?

Which dosage 1?

If yes, which medication 2?

Which dosage 2?

If yes, which medication 3?

Which dosage 3?

If yes, which medication 4?

Which dosage 4?

Declaration of consent for data usage for additional purposes

With my signature, I am providing consent that the Veterinary Practice Rosin Tiergesundheit Dienstleistungs GmbH can use my personal data provided on the registration form for the realisation of a veterinary treatment contract on the basis of legal permissions. Any usage of the personal data and collection of additional information extending beyond this, including forwarding of the data to third parties, requires your consent on a regular basis. You can provide such consent voluntarily hereinafter.*

I give consent that the collected data can also be used for future veterinary treatment contracts.*

I give consent that the collected data can be forwarded to other veterinary practices and clinics if required and necessary in the context of veterinary referrals.*

I give consent that the collected data can be forwarded to laboratories and institutes if required and necessary in the context of further diagnostics.*

I give consent that the veterinary practice Rosin Tiergesundheit Dienstleistungs GmbH can inform me about laboratory results and scheduling via telephone and/or e-mail.*

I give consent that the veterinary practice Rosin Tiergesundheit Dienstleistungs GmbH can inform me by postal mail.*

I give consent that collected data can also be used as intended in the context of the continuation of the practice by a successor.*

Declaration of consent for the sending of unencrypted e-mails

1. I hereby give my consent as principle, that all e-mail communication between me and the above mentioned veterinary practice can unconditionally be sent in an unencrypted form.

2. 2. This consent is also valid for data which is provided to third parties on my behalf (e.g. laboratory institutes, in cases of referrals to other practices). (Cross out if applicable).

3. 3. According to § 17 of the General Data Protection Regulation, I have the right to require Rosin Tiergesundheit Dienstleistungs GmbH to delete and suspend my personal individual data at any time.
Furthermore, I can make use of my right to object without providing any reasons and change my given consent with future effect or withdraw it entirely. The withdrawal is to be sent to Rosin Tiergesundheit Dienstleistungs GmbH by postal mail, via e-mail or fax
.

Consent*

How did you find out about our practice?

Other remarks

Spam protection*: How much is 3x3? (Enter result below)

»Link to Terms and conditions
I have read and agreed to the Terms and conditions