Insurance Claim Examination Certificate
Policyholder Details
- First name
- Last name
- Address
- Phone
- Insurer
- Policy number
- Claim number
Patient's Details
- Name
- DOB (age)
- Microchip
- Weight (kg)
- Gender
- Species
- Breed
- Colour
Clinical Details
- Date of examination
- Date clinical signs first noted
- Presenting problem / diagnosis
- Related to a previously diagnosed or pre-existing condition?
- Ongoing treatment expected?
- Details
- Treatment provided
Fees
- Total fees for this condition ($)
- Invoice numbers and dates
Veterinary Certification
I, the undersigned veterinary practitioner, certify that the information recorded on this certificate is true and accurate, based on my examination of the animal and the clinical records held by this practice. In my opinion the treatment described was reasonably necessary for the condition recorded. The clinical records relating to this claim are available to the insurer on request, with the policyholder's consent.
- Veterinarian name
- Registration number
- Date signed
Veterinarian signature
Clinic stamp
