Walt’s World Community Clinic Follow-Up Request Form

Walt’s World Community Clinic Follow-Up Request Form

Community Access Clinic | Internal Review
SECTION 1: CLIENT INFORMATION
Owner/Guardian Full Name*
Phone Number*
Email Address*
EmailPhone - TextPhone - Call (Response time is significantly delayed if this is your preferred method of communication)
SECTION 2: PET INFORMATION
Pet’s Name*
DogCatOther
Approximate Age*
Date of Walt’s World Clinic Visit*

MonthDayYear
Date
SECTION 3: CLINIC SERVICES RECEIVED

(Check all that apply)
VaccinesSpay/NeuterExam onlyMedications dispensedLab workNot sure
SECTION 4: FOLLOW-UP QUESTION TYPE
Question about medications given at the clinicQuestion about lab results from the clinicMild side effects discussed at the appointmentSymptoms improving but not fully resolvedMy pet needs additional medication or a refillMy pet needs to be recheckedNew or worsening symptomsMy pet is not eating / bleeding / having breathing issues
SECTION 5: SYMPTOM DETAILS
Please describe what you are seeing*
SECTION 6: SAFETY CHECK
Not eating for 24+ hoursBleedingBreathing difficultiesSevere painRapid declineNone of the above
SECTION 7: REQUIRED ACKNOWLEDGEMENTS
I understand Walt’s World clinics do not provide ongoing medical careI understand volunteers cannot diagnose, prescribe, or adjust medicationsI understand I may be referred to a full-service or emergency veterinarianI understand submitting this form does not guarantee veterinary review
Thank you for reaching out. If your concern is outside the scope of our clinic services, you will be referred to a full-service or emergency veterinarian. For urgent issues, please do not wait for a response.
Should be Empty:

Walt’s World Community Clinic Follow-Up Request Form

SECTION 1: CLIENT INFORMATION

SECTION 2: PET INFORMATION

SECTION 3: CLINIC SERVICES RECEIVED

SECTION 4: FOLLOW-UP QUESTION TYPE

SECTION 5: SYMPTOM DETAILS

SECTION 6: SAFETY CHECK

SECTION 7: REQUIRED ACKNOWLEDGEMENTS

Thank you for reaching out. If your concern is outside the scope of our clinic services, you will be referred to a full-service or emergency veterinarian. For urgent issues, please do not wait for a response.