Javascript Booking Form 1

Australian Equine Dental Practice^TM
© Peter Borgdorff 1984-2004
BOOKING PAGE
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Read the disclaimer.

AUSTRALIAN BOOKINGS

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IMPORTANT
This form will send in Outlook, Netscape and Thunderbird but some clients have experienced problems sending this form by other means. If you prefer, you may send your details via E-mail

Kindly complete fields marked * and other appropriate fields.

Use this form to request a booking in certain areas in Victoria and New South Wales, Australia. As soon as the training and affiliation of equine dentists in other areas occurs we will advise you on the Associates Page.

Upon receipt we will enter this information into the Australian Equine Dental Practice client database.

1) Name*

2) E-mail address: *

3) Have you had any horses treated in the last 18 months? *
No
Yes
If yes, skip questions 3-10 and go to 11.

4) Street or road address (incl. property name if any):

5)Town/city:

6) State:

7) Postcode:

8)Home phone number:

9) Mobile phone number:

10) If applicable what is your work phone number?

11) For how many horses do you require treatment?
12) What type of horse activity are you MOST involved in?
Racing
Trotting
Dressage
Eventing
Showjumping
Western pleasure
Polo/polocrosse
Campdrafting
Endurance
Pony club
Leisure riding
Other:

13) Any other comments?

14) What response would you like from us?
Please E-mail with appointment confirmation
Please E-mail an appointment and advise me of site updates
Please ring with an appointment
Please ring with an appointment and E-mail me site updates

15) Click 'SUBMIT' once then click the 'CLOSE' button. IMPORTANT
If no response is received within 48 hours, please send a brief E-mail and I will contact you. There have been some reports of difficulties sending this booking form. Our apologies-this will be rectified when our new site is completed.