VETERINARY USE ONLY
For a custom fee scale proposal and a return on investment statement, please complete the following questionnaire:
First Name:
 Last Name:
Title:
 Clinic Name:
Address:
 City:
State/Province:
 Zip:
Country:
 E-Mail:
Phone:
 Fax:
What is your primary practice?  Small Animal   Equine   Exotics
Veterinary school attended? 
Year of graduation? 
Do you own a practice or clinic?  Yes   No   How many? 
Percentage of patients treated that are chronic?  %
Percentage of patients treated that are acute?     %
Average patient bill?  $ (Optional)
Average yearly billables?  $ (Optional)

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