Community Vet Clinic - Client Eligibility Questionnaire Next Clinic day: Saturday, Sept 26, 2026, 9a-2p
Helping us serve those who need it most. All responses are confidential.
You will need to complete one application PER PET for us to best assess your needs! You can do an unlimited amount of applications. Once applications close on Sept 11, 2026, we will be in touch to let you know if your application has been accepted. Please reply to emails or texts promptly as spots may fill up before you reply. The clinic is first come first served for approved applications.
Applications close on September 11, 2026. You will be notified if you've received a time slot after the 11th. You must be able to pay no later then Sept 18 2026 to secure your spot for the Saturday, Sept 26 2026 Clinic Day
Household Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County (Hart, Stephens, Franklin, Elbert)
1. What is your total monthly household income (before taxes)?
*
Under $1,000
$1,000 - $1,999
$2,000 - $2,999
$3,000 - $3,999
$4,000 or $5,999
$6,000 or more
2. How many people live in your household
*
3. Are you currently receiving any of the following assistance? (Check all that apply) SNAP (Food Stamps)Medicaid / Medicare Disability (SSI / SSDI) Unemployment Benefits Housing Assistance
*
SNAP (Food Stamps)
Medicaid / Medicare
Disability (SSI / SSDI)
Unemployment Benefits
Housing Assistance
None
Other
Pet Household Information
4. How many pets currently live in your household
*
5. How many of your pets are in need of veterinary care today?
*
6. When was the last time your pet(s) received veterinary care?
*
6-12 months ago
Over a year ago
Never received veterinary care
7. Have you received any previous support for your pets? Examples: free clinic, pet food pantry, mobile vet, rescue group, etc.
Free Clinics
Pet Food Pantry
Mobile Vet
Rescue Group
Other
8. May we contact you about future support services, resources, or upcoming clinic events?
Yes
No
Phone Number
Format: (000) 000-0000.
Email
example@example.com
8. May we use photos taken at the clinic day of you and your pet in our social media, marketing, website, grant applications, and outreach flyers?
Yes
Yes, but just my pet
No
Please complete this section for
each pet
you're needing assistance with.
Pet Name
*
Pet Species
*
Cat
Dog
Other
Breed if known
*
Community Vet Clinic- Client Eligibility Questionnaire
Pet Age approximate
*
Pet Sex
*
Please Select
Male
Female
Unknown
Pet Spayed/ Neutered:
*
Please Select
Yes
No
Unknown
Pet Previously Vaccinated
*
Please Select
Yes
No
Unknown
Pet Current Concerns or Symptoms: (Check all that apply)
*
Itching / Scratching
Hair Loss
Ear Issues (shaking, redness, discharge)
Eye Issues (discharge, squinting)
Wounds or Sores
Coughing/Sneezing
Limping
Weight Loss or Weight Gain
Other
If you have pets that are NOT spayed and neutered, are you willing to receive help in getting them spayed and neutered?
Yes
No
Yes, but only after I breed them.
Tell us more in the box below. Please elaborate on what you are needing assistance with for your pets. The more information and details you can share the better. Please include your additional pets information in the space below if you cannot fit it above. We need to know Name, Age, if they are Spayed/Neutered, etc.
Thank you for filling out the Walt's World Low Cost Vet Clinic Form. Please press SUBMIT below. You will be contacted via email or text message about further steps. Please wait to hear from us if you are eligible for the clinic and await further instructions. Do not show up to the clinic day unless you have received confirmation and a timeslot. Thank you.
Submit
Should be Empty: