White Hall Animal Clinic New Client Application Form
This application aims to gather comprehensive information from potential new clients, focusing on their commitment to their pet's health, their understanding and expectations of veterinary care, and their willingness to engage in recommended treatments and preventive measures. The responses will help the clinic determine if we are the best fit your pet care needs.
Responses
A manager will review your application information and reply by email within 5 business days. If your pet needs sooner than that, please note it below. If your pet is ill and needs seen right away, we recommend you take your pet to Urgent Care or Emergency Clinic for care.
Owner Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Why White Hall Animal Clinic?
*
What are the most important factors for you when choosing a veterinary clinic?
*
How do you define a successful veterinary visit?
*
How important is preventative care to you for your pets? (Preventative care = vaccines, parasite preventions, yearly blood work and parasite tests)
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How well do you trust your current veterinarian?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How often do your pets see the veterinarian?
*
Only when sick
Multiple times a year
Yearly for vaccines
Frequently, as often as needed
What do you feed your pet(s)?
*
Total number of pets owned
*
Name of the pet needing to be seen:
*
Age of the pet needing seen:
*
Species for the pet needing seen:
*
Dog
Cat
Other
Sex of pet needing seen:
*
Male
Female
Spayed/Neutered
Breed of the pet needing seen:
*
Last veterinary visit for this pet and where:
*
Reason this pet needs seen:
*
List all current treatments and medications and if they are helping.
*
List all previous treatments and medications and if they helped.
*
Do you have any additional information, questions, or concerns to share?
*
Please list any specific days or times that work best for you to find you an appointment.
*
Do you want to be placed on the cancellation list? If yes, please list days and times of days that you could come in on short noticed. Also, please tell us how much notice you would need to arrive for an appointment.
*
Thank You
Thank you for taking time to complete this form. Due to limited appointment slots, a manager will review your information and our schedule and get back to you. You will also be placed on the cancellation list if you selected that option.
Submit
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