New Account Profile

Please Print this form and Fax it to 1(631) 218-2875 or Mail it to:
P.O. Box 9002
155 Knickerbocker Avenue
Bohemia, NY 11716

Clinic Name:______________________________________________________________

Doctor's Name:____________________________________________________________________

Primary Contact Name:______________________________________________________

Clinic Address:_____________________________________________________________

Town:________________________________________State:_______________Zip______

Phone Number:________________________ Fax Number:__________________________

Email Address______________________________________________________________

Is Your Practice Primarily: Large Animal:_________ Small Animal_________ Mixed_____

How Many Veterinarians are There on Staff:_{___________________________________________}

_{Are There Any Board-Certified Members of the Veterinary Staff?  Yes_______ No_____}

_{If Yes, What Discipline are They Certified in?____________________________________}

_{Does Your Clinic Have A Fax Machine?   Yes______________ No________________}

_{Would You Like to Receive Our Monthly Fax Specials?  Yes_______ No__________}

_{Do You Prefer to Order Products on an As-Needed Basis? Yes________ No_________}

_{Or, Do You Prefer to Stock-In to Take Advantage of Special Savings or Quantity Breaks?}

_{Yes____________ No__________}

_{Would You Like To Be Contacted About Special Closeout Deals or Overstocks?}

_{Yes_________ No_____________}

_{If Yes, How Would You Like Us to Contact You?}

_{By Phone______ By Fax____ By Email_____}

_{Average Amount of Supplies Purchased Per Month_______________________________}

_{Which Distributor Do You Primarily Use For Your Veterinary Supplies?_____________}

_{What, If Anything, Would You Like Changed, Added, or Offerred From Distributors in Order to Make Your Purchasing Easier?___________________________________________________________________}

_{__________________________________________________________________________}

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_{Thank You Very Much For Your Time.}