WAG Partners Name of Veterinary Practice(Required) Contact Name(Required) First Last Contact Title(Required) Contact Phone(Required)Contact Email(Required) Veterinary Practice Owner (if different than contact): Website(Required) Please upload a high resolution logo of your practice: (not mandatory) Drop files here or Select files Max. file size: 2 GB. Please provide links to your social media (i.e. Facebook, Twitter, Instagram, etc.) one per line.(Required)Address of Practice(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Hours of Operation(Required) Do You Offer After Hours Emergency Services?(Required)YesNoNumber of Veterinarians at Practice(Required)Number of Employees at Practice(Required)Years in Business(Required)Do you specialize?(Required)YesNoTell us about your practice and what differentiates you from other practices:(Required)Average Number of Pets Treated per Month(Required)0-5051-100101-200201-300301-400Over 400Percentage of Emergency Cases per Month(Required)0-10%10-20%20-30%30% Or MoreEst. Percentage of Clients Unable to Afford Emergency Care(Required)0-10%10-20%20-30%30-40%40% or AboveDoes your practice offer or suggest any of the following funding sources to clients who are unable to afford emergency care? (Check all that apply)(Required) CareCredit, ScratchPay or other veterinary credit service Waggle Crowdfunding for Pets Internal payment plan Internal angel fund Other source(s) Please list any other source(s) of funding options offered or suggested to clients who can not afford emergency care: * Please list any other source(s) of funding options offered or suggested to clients who can not afford emergency care:(Required) What discount do you provide for Not for Profits, if any?(Required) Saving Gracie relies 100% on community donations. In an effort to help us increase donor awareness, would you be willing to include us in your marketing &/or client communications when applicable?(Required)YesUnsure, need more informationNot at this timeI’m in! Here’s how we can help (choose all that apply):(Required) Posters/Brochures/Window Clings Donation Box Round-ups/donations at checkout Social Media/Website/Email Other How did you hear about Saving Gracie? *(Required)Postcard in the MailClientStaff MemberOnline SearchSocial MediaOther, (Please describe below)Specify Other(Required) If you would like to add comments, offer suggestions, ask questions, or bark some orders, this is a purr-fect opportunity to do so!Wanna fetch Gracie’s Gazette Quarterly Email Newsletter? It’s filled with dog-gone good news! You can opt out any time seriously…we’re not kitten!(Required) Yes please! No thanks, maybe later. CAPTCHA
