Full Name(*)
Invalid Input

Email(*)
Invalid Input

Phone (W)
123-456-7890(*)
Invalid Input

Phone (H)
123-456-7890(*)
Invalid Input

Mobile
123-456-7890(*)
Invalid Input

FAX
123-456-7890
Invalid Input

Physical Address
Address:
State:     ZIP:(*)
Invalid Input

Mailing Address
(if different)

Address:
State:     ZIP:
Invalid Input

Veterinary School
Veterinary School:
Qualifications:
Year of Graduation:(*)
Invalid Input

State Veterinary Medical Board
and Licence number
Invalid Input

Practice Name/Place
where relief service provided
Invalid Input

Company name
(if applicable)
Invalid Input

Professional Activity
Invalid Input

Names of Other Veterinarians in Your Practice
(Please complete a separate application for membership
for each member in your practice)
Other Veterinarians in Your Practice
Invalid Input

List of all prior Claims & Board complaints
Material non-disclosure of prior Complaints and Claims may
lead to loss of membership benefits and insurance cover.
List of all prior Claims & Board complaints
Date: Details: Outcome:
Invalid Input

I Agree to the Terms & Conditions below for VDA America
Membership and the discretionary mutual defense fund
(*)
Invalid Input

VDA Membership Check or EFT Total
0.00 USD

If you wish to pay by electronic bank fund transfer (EFT).
Please contact the VDA Office at 7911 Timbercreek Lane, Unit G, North Charleston, South Carolina, 29418 or telephone TOLL FREE: 855 757 5700 or email to Request EFT Bank details. Proof of payment, together with the completed membership application form
may be scanned and e-mailed to info@vetdefenceco.com.

If you wish to pay by check
Mail check to VDA America, 7911 Timbercreek Lane, Unit G, North Charleston, South Carolina, 29418 together with a completed scanned application form.
Check/EFT Payment



VDA Membership Agreement


I agree to the following terms and conditions:

1. The VDA material that will be supplied to me during the period of my membership is strictly copyrighted and I agree not to copy or disseminate this material in any manner for any purpose outside of my practice or to non-VDA members, especially, but not limited to, VDA consent forms. I agree to destroy or delete all of this material upon termination of my VDA membership.

2. I understand that it is recommended that I should remain a VDA member for the duration of my career as a practising veterinarian and that I should apply for run-off protection and insurance cover for at least three years after I retire.

3. I understand that resignation takes place at year-end by submitting a completed VDA Resignation Form (obtainable on application) and that I will be required to provide two months’ notice to the VDA of my intention to resign or retire as a member.

4. I will at all times act with the highest honesty and integrity towards the VDA, its insurers, partners, agents and associates.

5. In the event of a dispute with the VDA and/or its directors, consultants, staff, agents or representatives (‘the organization’), I agree to use the organization’s alternate dispute resolution procedures. I hereby absolve the organization from all actions, arising directly or indirectly from my membership.

6. I understand that membership and cover is provided subject to the terms of the Certificate of Membership and the Articles of Association of the VDA.

7. I understand that the VDA communicates with its members only by e-mail and on its website at http://vda-america.org/ especially but not limited to, the material contained in MyVDA. I agree that the onus is on me to receive, read, implement and abide by the contents thereof, and to notify the VDA of any changes to my e-mail address.

8. I will contact the VDA and will follow the VDA’s advice and guidance whenever I am faced with an incident, event, occurrence, adverse treatment outcome, situation, complaint, dispute or claim in my practice that may lead to a formal complaint or claim against me. I understand that, due to the difficulty experienced by VDA Consultants in making contact with its busy member practitioners, the onus will also be on me to continue the contact with the VDA Consultant as my matter or case progresses.

9. I will follow the protocols and will abide by the requirements contained in the VDA’s documentation, including the VDA’s Articles of Association, VDA website, membership and other application forms, VDA Bulletins, VDA Notices and VDA newsletters and I agree to abide by the VDA’s Claims Prevention Program and Claims Management Program.

10. I will use the approved VDA Informed Consent to Treatment Forms in accordance with VDA Bulletin 3. I accept that I will be obliged to produce a duly signed VDA-approved Consent to Treatment Form in order to be eligible for the VDA’s mutual defense fund benefit.

11. I will use the VDA certificates or a certificate that I have submitted to the VDA and has been approved by the VDA, in accordance with VDA Bulletins 4, 5 and 6. I will regularly refer to my online VDA File and information in MyVDA at http://vda-america.org/ and I will conduct a refresher course on this information at least once every six months with my veterinarians and staff and will review the contents with any new veterinarian or staff member that joins my practice.

12. I will notify the VDA immediately of any incident, event, occurrence, adverse treatment outcome, situation, complaint, dispute or claim arising against me or my practice and I will not communicate with the claimant, plaintiff or complainant or his or her legal representatives or anyone related to the claimant or plaintiff or any third party without the VDA’s knowledge and written consent.

13. I will do nothing that can be construed as colluding with the client/claimant/plaintiff and will do nothing to damage or circumvent the settlement or defense of the matter.

14. I undertake to supply all information and documents requested and/ or relevant to the matter timeously and to provide my full co-operation at all times.
ooOoo