Referring Veterinary Partner Discount: Pre-Registration

Referring Veterinary Partner Discount: Pre-Registration
Welcome to Allied Veterinary Emergency and Referral’s Veterinary Partner Discount Program Pre-registration.

Please fill out the following form to be eligible for our new Veterinary Partner Discount Program. This program is open to all veterinary employees, from DVMs to kennel assistants. We deeply value every role in the veterinary community and want to recognize your hard work.

Eligibility Requirements:
- Clinics must list Allied Veterinary Emergency & Referral on their website, voicemail, or both.
- You must complete this pre-registration form to be entered into our system for discount eligibility.
- At intake, proof of employment must be shown (recent pay stub within the last 30 days or staff name listed on clinic website).
- Only pets owned directly by you and living in your household are eligible for the discount. Friends’ and family pets are not eligible.
- Discount abuse or violation of these terms will result in removal from the program.
Important Instructions:
- Ensure the information entered is your personal information (no general clinic phone numbers, addresses, or emails). This will be used to create your electronic medical record.
- Entries without personal information will not be accepted.
Thank you for your participation, and we look forward to serving you and your pets!
Email*
example@example.com
Employer Facility Name (Hospital or Clinic Name)*
Preferred Allied Location (can select multiple)*

Brooklyn Park (24/7)Minneapolis (24/7)Eau Claire (24/7)RochesterEden Prairie

Your Contact Information

Please use your personal information as this will be used to create your medical record.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*We occasionally send out emails with information about Allied. You can unsubscribe at any time, and your email will never be sold or used for any purpose other than communications related to Allied Veterinary.
Personal Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Patient Information

Only pets owned directly by you and living in your household are eligible for the discount. Friends’ and family pets are not eligible. We only see canine and feline patients at this time.
Pet Name*
Species*
Age/DOB*
Sex*
Breed*
Do you have more pets you would like to register?*

YesNo

Patient Information

Only pets owned directly by you and living in your household are eligible for the discount. Friends’ and family pets are not eligible. We only see canine and feline patients at this time.
Pet Name*
Species*
Age/DOB*
Sex*
Breed*
Do you have more pets you would like to register?*

YesNo

Patient Information

Only pets owned directly by you and living in your household are eligible for the discount. Friends’ and family pets are not eligible. We only see canine and feline patients at this time.
Pet Name*
Species*
Age/DOB*
Sex*
Breed*

Authorization

By signing this form, you are ensuring that all information entered is correct and any pets listed are owned by you.
Today's Date*

MonthDayYear
Date
E-Signature*

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Referring Veterinary Partner Discount: Pre-Registration

Your Contact Information

Patient Information

Patient Information

Patient Information

Authorization