Application for low cost Veterinary services

Owner First Name *
Owner Surname *
Street Address *
City *
State *
Post Code *
Phone Number *
Email Address (non NT Gov or NT Schools email addresses please)(Please check spam folder as you will get an automatic email once you submit this form and future emails may also go there) *
Facebook Profile
Animal Name *
Species * What type of animal is your pet, cat dog bird?
Gender *
Breed *
Size *
Date of Birth *
Colour *
Is your pet Desexed *
Is your animal up to date on vaccinations *
What vaccination was given and on what date? *
Has your pet previously been flea, tick and worm treated?
What health issues does your pet have and what are you asking for help with? *
Please give as much detail as possible about your pet and what help it needs *
Date service required *
Have you previously seen a vet about this problem? *
Vet Clinic Name *
Vet Clinic Address *
What date did you see the previous vet clinic for this issues? *
Emergency Contact Name *
Emergency contact number *
I understand if payments are not made as agreed, and I am not able to be contacted, that the emergency contact person will be called to organise these payments. *
Does your animal have any known behavioural issues we need to know about that may impact staff safety? *
If yes above please supply details?
Please state the reason you are applying for low cost Veterinary care, please note that we are not wanting every detail of your life, just enough information to determine if your need is genuine as we have limited places. * please give us some details about why you need some support this will reduce face to face questions and your information is confidential
Our practice will charge a fee that covers our costs, the treatment you require for your pet, and will depend on your circumstances, not on the set rate of the procedure. *
Owner agrees to pay the total amount agreed to on the due dates. *
You agree that while the PAWS Darwin Community Vet is able to support your pet with treatment sometimes things do not go right and you agree not to hold the PAWS Darwin Community Vet responsible if treatment does not go to plan *
Owner specifically represents that they lawfully own pets listed in this Agreement *
Owner understands that the pet shall not leave the vet clinic until all fees and charges are paid in full, or a payment plan has been agreed to and signed. Daily fees continue to accrue until this time. The daily rate will be discussed with you at time of admission. *
I understand that should I not follow up on all my commitments my pet will not be eligible for further care. If you are unable to meet any obligations you need to contact us to make new arrangements. Volunteering and other support may be accepted as part of your agreement. *
Owner agrees where required to desexing pet under the PAWS Darwin low cost desexing clinic.
Signature of Applicant. Please use your finger on touch screen or click and hold your left button to use your mouse above the line. * Please sign on screen or click and hold your left button to use your mouse.
Date *
Please up load a copy of your drivers licence or 18 plus card *
Please take a picture of your Health care card or other cards showing your eligilbility * If you do not have a Health care card but are still struggling please continue with the process if you have given us the relevant information we may still be able to offer you support.
I am aware that i am able to use my basics card at the PAWS Darwin Community Vet Clinic *