Vet Clinic Referral Request Tiny Vet Clinic
This form is for financially disadvantaged clients who need assistance for chronic conditions or have difficulty accessing veterinary care due to lack of transport. We will contact pet owners on completion of this form, but cannot guarantee the TVC will be able to see them immediately. This service is subject to availability of volunteers and resources. The clinic will also not be performing procedures or surgeries. We encourage pet owners to contribute towards the cost of their pet's care by paying cost price for medications, vaccinations and other treatments, however consultations will be free of charge.
Are you a Veterinary Clinic
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Yes
No
Name of referring Vet Clinic
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Please tell us which clinic you are applying from
Referring Vet Clinic phone number
*
Please enter a valid phone number.
Format: (00) 00000000.
Referring Vet Clinic email
*
example@example.com
Staff member name filling out the form
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Client's Name
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First Name
Last Name
Does the client have a Healthcare Card and/or are they on a Centrelink payment
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Yes
No
Not sure
Email address of client
*
If they do not have one use none@none.com
Phone Number of client
*
Use all zeros if no number
Format: (0000) 000-000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's Name
*
Species
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Cat
Dog
Other
Breed
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Sex
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Male
Female
Desexed?
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Yes
No
Unknown
Age or Date of Birth of Pet
*
Best guestimate will do
What conditions does the pet have that need to be managed or treated?
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Please upload a history here or email to actpetcrisis@gmail.com
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