Practice Membership Inquiry
Practice Membership Information Form
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Practice Membership inquiry form
For an overview of the program, click
to view the Practice Membership Flyer.
If you would like to receive a proposal for a pvma practice membership for your practice, please complete the following information.
Name of Person Filling Out This Form
NAME OF PRACTICE
Type of Practice
Small Animal, Large Animal, Mixed Animal, Specialty & Emergency, etc.
Practice Owner Name(s)
If you have more than one location, please list any additional addresses here
General Email Address
Please indicate the total number of full-time or full-time equivalent Veterinarians employed at your practice:
i.e. - 2 part-time veterinarians equals 1 full-time equivalent
Please indicate how many of your Veterinarians are recent graduates:
2013 Veterinary Graduates
Please indicate how many Veterinarians graduated in 2013.
2014 Veterinary Graduates
Please indicate how many Veterinarians graduated in 2014.
2015 Veterinary Graduates
Please indicate how many Veterinarians graduated in 2015.
2016 Veterinary Graduates
Please indicate how many Veterinarians graduated in 2016.
Do you have a Practice Manager?
Please indicate the total number of full-time or full-time equivalent Certified Veterinary Technicians employed at your practice:
Please indicate the total number of full-time or full-time equivalent Veterinary Assistants employed at your practice:
Please indicate the total of additional support staff (full-time or full-time equivalent) employed at your practice:
Additional staff may include Office/Hospital Manager, Office Support Staff, Client Service Representatives, Receptionist, Kennel Attendants, etc.
Additional comments or questions
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Phone: (717) 220-1437 | Fax: (717) 220-1461 |