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
*
Preferred Method of Contact
*
Email
Phone - Text
Phone - Call (Response time is significantly delayed if this is your preferred method of communication)
SECTION 2: PET INFORMATION
Pet’s Name
*
Species
*
Dog
Cat
Other
Approximate Age
*
Date of Walt’s World Clinic Visit
*
-
Month
-
Day
Year
Date
SECTION 3: CLINIC SERVICES RECEIVED
(Check all that apply)
What services did your pet receive at the clinic?
*
Vaccines
Spay/Neuter
Exam only
Medications dispensed
Lab work
Not sure
SECTION 4: FOLLOW-UP QUESTION TYPE
What best describes your concern?
*
Question about medications given at the clinic
Question about lab results from the clinic
Mild side effects discussed at the appointment
Symptoms improving but not fully resolved
My pet needs additional medication or a refill
My pet needs to be rechecked
New or worsening symptoms
My pet is not eating / bleeding / having breathing issues
SECTION 5: SYMPTOM DETAILS
Please describe what you are seeing
*
SECTION 6: SAFETY CHECK
Is your pet experiencing any of the following?
*
Not eating for 24+ hours
Bleeding
Breathing difficulties
Severe pain
Rapid decline
None of the above
SECTION 7: REQUIRED ACKNOWLEDGEMENTS
Please confirm the following:(Checkboxes – ALL REQUIRED)
*
I understand Walt’s World clinics do not provide ongoing medical care
I understand volunteers cannot diagnose, prescribe, or adjust medications
I understand I may be referred to a full-service or emergency veterinarian
I 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.
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