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Please fill in the requested information on the following form. This will help us in understanding your practice and will enable us to provide you with the right configuration. PracticeVeterinary is flexible enough to accommodate the requirements of a small single doctor clinic or a large multi-hospital group having emergency, referral, boarding, and other advanced facilities at each of their clinics. Once you submit the following information, one of our sales executives will contact you to schedule a consulting session and will suggest the right PracticeVeterinary configuration for your practice.
General Information
Full Name:
Practice Name:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
How did you hear about PracticeVeterinary^SM ?
What are you looking for in a new practice management system?
Practice Information
Does your hospital have broadband Internet connectivity?	Yes No
How many computer/workstations do you have in you practice?
How many of them are Internet enabled?
Do you have multiple sites?	Yes No
Please provide number of staff members:	-Veterinarians -Technicians -Others
Do you currently use any Practice Management System? If Yes, then which one?	Yes No
Type of Operating System:
Are you using software for any other activity ? (e.g. Accounting)	Yes No
How do you send reminders ?
Are you currently outsourcing payroll ?	Yes No
Number of active clients :
How would you best classify your practice?