Walt's World Vet Clinic Eligibility Questionnaire

Community Vet Clinic - Client Eligibility Questionnaire

Next clinic day: Saturday, January 31 2026 9am-2pm

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 January 20, 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.

Pre-Registration closes on January 20, 2026. You will be notified if you've received a time slot. You must be able to pay no later than January 26,2026 to secure your spot for the Saturday, January 31 2026 Clinic Day.
Household Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 / MedicareDisability (SSI / SSDI)Unemployment BenefitsHousing AssistanceNoneOther
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 agoOver a year agoNever 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 ClinicsPet Food PantryMobile VetRescue GroupOther
8. May we contact you about future support services, resources, or upcoming clinic events?

YesNo
Phone Number
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?

YesYes, but just my petNo
Please complete this section for each pet you're needing assistance with.
Pet Name*
Pet Species*

CatDogOther
Breed if known*
Pet Age approximate*
Pet Sex*
Pet Spayed/ Neutered:*
Pet Previously Vaccinated*
Pet Current Concerns or Symptoms: (Check all that apply)*

Itching / ScratchingHair LossEar Issues (shaking, redness, discharge)Eye Issues (discharge, squinting)Wounds or SoresCoughing/SneezingLimpingWeight Loss or Weight GainOther
If you have pets that are NOT spayed and neutered, are you willing to receive help in getting them spayed and neutered?

YesNoYes, 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. Thank you.
Should be Empty:

Household Information

Pet Household Information

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. Thank you.