Full Name(*)
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Preferred Name
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Email(*)
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Phone (W)
123-456-7890(*)
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Phone (H)
123-456-7890(*)
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Mobile
123-456-7890(*)
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FAX
123-456-7890
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Physical Address
Address:
State:     ZIP:(*)
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Mailing Address
(if different)

Address:
State:     ZIP:
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Veterinary Faculty
Veterinary Faculty:
Qualifications:
Year of Graduation:(*)
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State Regulatory Body
and Registration number
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Practice name or place of locum
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Company name
(if applicable)
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Professional Activity
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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
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Statement of all prior Claims & Board complaints
Material non-disclosure of prior Complaints and Claims may
lead to loss of membership benefits and insurance cover.
Statement of all prior Claims & Board complaints
Date: Details: Outcome:
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VDA Membership Options:
I understand that, should I choose to be insured under the VDA program, my membership and insurance information
will be shared between the VDA and the VDA’s broker ACE-IRM, and the underwriters and insurer for the VDA program.


1. I hereby select the following VDA membership option:
(*)

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[VDA membership is not available to members carrying professional indemnity insurance cover
other than the insurer for the VDA program PI cover].

2. In the event that I have selected 1.1. To insure using the VDA program cover, I hereby provide the VDA with instructions to obtain
a quote for the aforesaid insurance cover on my behalf and agree to provide all relevant information that is required for obtaining this.
I understand that membership is provided subject to the terms of the Certificate of Membership, the Articles of Association, VDA
Bulletins, the policy and the VDA-ACE-IRM-insurer for the VDA program agreement and that I agree to abide by the VDA’s
Complaints Prevention Program and Complaints Management Program. Membership follows the policy year, which is
1 June to 31 May and in the first year is pro-rated accordingly.

3. In the event that I have selected 1.2. To self-insure against all claims against me, I understand that I have no cover for claims and
that all awards and legal costs are for my account. I accept that membership is provided subject to the terms of the Certificate
of Membership and the Articles of Association. Membership follows the VDA’s financial year, which is 1 June to 31 May.

4. I understand that the VDA communicates with its members only by e-mail and on its website at www.veterinary-defence-association.org
and 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.

5. INSURANCE ENDORSEMENT REQUEST:
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(*)
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I further understand that I am still required to adhere to clause 6.4 of the Policy regarding the necessity for Consent Forms,
especially with regard to the use of the VDA’s high value consent form.
(*)
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VDA Membership Fees for 2019/2020(*)

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VDA Membership PayPal Total
0.00 AUD

PayPal Payment



VDA Membership Agreement


I agree to the following terms and conditions, as amended:

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 practicing 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. I understand that membership and cover is provided subject to the terms of the articles of association of the VDA.

6. I understand that the VDA communicates with its members only by e-mail and on its website at http://vda-australia.org and that the onus is on me to read and understand all published material, 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.

7. 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.

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 familiarise myself with the obligations and exclusions contained in the policy.

10. 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.

11. I will use the approved VDA Informed Consent to Treatment Form in accordance with VDA Bulletin 3. I accept that I will be obliged to produce a duly signed VDA approved Consent to Treatment Form for every claim, failing which the insurers are entitled to refute the claim. If I am a Locum or Practice Assistant at a non-VDA member practice, I acknowledge that I must supply a copy of the practice’s Consent to Treatment form to the VDA for approval in order to comply with Clause 6.4 of the policy wording.

12. I will use the VDA certificates or a certificate that I have submitted to the VDA and which has been approved by the VDA, in accordance with VDA Bulletins 4, 5 and 6.

13. I will regularly refer to my online VDA File and information in MyVDA at http://vda-australia.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.

14. 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.

15. 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 defence of the matter.

16. 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.