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 Please leave this field empty.Please leave this field empty. Information about the owner Title* ---Mr.Ms.Diverse First name* Last name* Street* Nr. Postcode* City* Country* ---AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis and FutunaWestern SaharaSamoaYemenZambiaZimbabwe Phone/Mobile* Email* »Link to overview/date cooperation practices Location of the agreed appointment?* ---Biebergemünd - VETPraxis für Kleintiere GmbHBerlin-Charlottenburg - Tierarztpraxis RosinFalkensee - Tierarztpraxis RosinGiebenach near Basel (CH) - Tierarztpraxis MahnckeWalldorf - Tierarztpraxis Dr. Heike HildebrandWolfratshausen - Fachtierarztpraxis Dr. Max Hildenbrand 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?* ---CashEC- or VISA-paymentDirect payment through insurance under certain conditionsInvoice via BFS (installments payments www.bfs-health-finance.de)Not specified »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?* ---YesNoNot specified 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* ---YesNoNot specified 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?* ---Yes, I am the ownerNo, I am a client acting in authority (see Terms and conditions nr. 9 and nr. 10)Not specified Species and breed* Name* Date of birth* Mac user enter the date as follows: yyyy-mm-dd (e.g. 2020-05-04) Sex* ---MaleFemale Weight in kg* Neutered* ---YesNo Color* Chip-nr. Pre-existing conditions (heart, liver, kidney, etc.)?* ---YesNoNot specified If yes, please describe briefly* I would like to send pictures/data* ---YesNoNot specified 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 email@example.com with your first and last name in the message Long-term medications?* ---YesNoNot specified 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.»More information here (in german)! 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.* ---Yes I give consent that the collected data can also be used for future veterinary treatment contracts.* ---Yes 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.* ---YesNo I give consent that the collected data can be forwarded to laboratories and institutes if required and necessary in the context of further diagnostics.* ---YesNo 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.* ---YesNo I give consent that the veterinary practice Rosin Tiergesundheit Dienstleistungs GmbH can inform me by postal mail.* ---YesNo I give consent that collected data can also be used as intended in the context of the continuation of the practice by a successor.* ---YesNo 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* ---YesNo 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 The binding treatment or service contract is only realized when the appointment is observed on site in our practice. We kindly ask you to cancel the appointment in good time if you do not want to keep the appointment.