Intake Form

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I am a veterinary student in this year’s class

I am an associate/relief veterinarian in practice

I am a veterinarian and practice owner

I am a resident/fellow/intern

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Disclaimer

For us to have a better understanding of who you are, where you are currently at in life, and where you are going- please complete our intake form. Obtaining these answers is critical to your planning and will allow us to prepare for your meeting ahead of time. The more information we have, the better we can assist you. It should only take a few minutes to complete the form, and we look forward to speaking with you soon!

Tell us a little bit about you

Name(Required)

School(Required)

State(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Tell us about your work

Area of Practice(Required)

Small

Mixed

Large

Equine

Other

Percentage Breakdown Small vs. Large(Required)

How many hours a week do you work?(Required)

Already filled out this form

I have already filled out this form in the past and I have no changes to make since I last filled out the form.

Where do you live

Current State(Required)

State after graduation (if known)

What are your future plans?

I have signed a contract(Required)

Yes

Signed Contract(Required)

Internship

Private Practice

Corporate Practice

I want to be boarded(Required)

Private Practice Name(Required)

Corporate Practice Name(Required)

Area of Practice(Required)

Small

Mixed

Large

Equine

Other

Percentage Breakdown Small vs. Large(Required)

Work Start Date (if known) or Estimated Date(Required)

MM slash DD slash YYYY

At this point in time, I expect to or have in interest in doing this after graduation(Required)

Internship

Private Practice

Corporate Practice

I want to be boarded(Required)

Private Practice Name(Required)

Corporate Practice Name(Required)

Area of Practice you are considering(Required)

Small

Mixed

Large

Equine

Other

Percentage Breakdown Small vs. Large(Required)

Approximate Work Start Date(Required)

MM slash DD slash YYYY

Income

What is your base salary number at your new job?(Required)

Income

What is your expected or anticipated salary range after graduation?(Required)

Student Loans and Related Information

Current Amount of Loans(Required)

Expected Amount at Graduation(Required)

Do you have a significant other/finance/spouse(Required)

Yes

Significant Other/Finance/Spouse Income(Required)

Significant Other/Finance/Spouse Loan Amount(Required)

Do you want to own your own practice one day?(Required)

Yes

Do you want to own your own home one day?(Required)

Yes

Are you going to the breadwinner of your family?(Required)

Yes

Tell us about your work

Type of Practice(Required)

Private Practice

Corporate Practice

Relief

Type of Practice(Required)

Private Practice

Corporate Practice

Corporate Practice Name(Required)

Please list any corporate practices you work with(Required)

Area of Practice(Required)

Small

Mixed

Large

Equine

Other

Percentage Breakdown Small vs. Large(Required)

How many hours a week do you work?(Required)

Are you planning on making a job change in the next 180 days(Required)

Yes

How can we help you today?

How can we help you today?(Required)

Individual Disability Insurance

Overhead Expense Insurance

Life Insurance

Group Benefits

Please upload your previous year business tax return at the end of the form.

If you are starting a practice, please indicate that at the end of the form.

How many full-time employees do you employ?(Required)

How many part-time employees do you employ?(Required)

Do you currently offer benefits?(Required)

Yes

What do you currently offer?(Required)

What would you like to improve in what you offer?(Required)

When is your renewal date?(Required)

MM slash DD slash YYYY

What would you like to offer?(Required)

Annual income

What is your annual income?(Required)

Do you expect a change in income soon?(Required)

Yes

What is your expected new income?(Required)

Do you have any current coverage?

Disability Insurance

Short-term disability

Long-term disability

Waiting period(Required)

Benefit Period(Required)

Voluntary or employer paid (voluntary = you pay for it)(Required)

Life Insurance(Required)

Yes

Life Insurance Amount(Required)

Individual or group(Required)

Health History

*All information will be kept confidential*

Height(Required)

Weight(Required)

Do you use any tobacco products (to include but not limited to smoking, dip, pouches, hookah, etc) or marijuana products?(Required)

Yes

Describe what and how often(Required)

Have you ever seen a doctor for or been diagnosed with any of the following conditions in the last 10 years?(Required)

ADD

ADHD

Anxiety

Asthma

Back Problems

Cancer

Depression

Diabetes

Epilepsy

Glaucoma

Frequent headaches or migraines

Heart disease

High blood pressure

Kidney or liver disease

Knee injury or surgery

Mental illness

Rheumatoid arthritis

Sleep apnea

Stroke

Surgery

Ulcerative colitis or crohn's disease

Vascular disease

Multiple Sclerosis

Alzheimer's Disease

Other medical conditions

None of the above

ADD(Required)

ADHD(Required)

Anxiety(Required)

Asthma(Required)

Back Problems(Required)

Cancer(Required)

Depression(Required)

Diabetes(Required)

Epilepsy(Required)

Glaucoma(Required)

Frequent headaches or migraines(Required)

Heart disease(Required)

High blood pressure(Required)

Kidney or liver disease(Required)

Knee injury or surgery(Required)

Mental illness(Required)

Rheumatoid arthritis(Required)

Sleep apnea(Required)

Stroke(Required)

Ulcerative colitis or crohn's disease(Required)

Vascular disease(Required)

Multiple Sclerosis(Required)

Alzheimer's Disease(Required)

Other Medical Conditions(Required)

Surgery Where?(Required)

Disability Insurance Policy Preferences

Do you want to be covered in your own occupation (veterinarian)?

Yes

Do you want a policy where the price cannot be changed by the insurance company without your permission?

Yes

Do you want a policy where the coverage cannot be cancelled by the insurance company without your permission?

Yes

Do you want policy where the benefits cannot be changed by the insurance company without your permission?

Yes

Do you expect your income to increase in the future?

Yes

I expect to make over $275,000 at some point in my career?

Yes

I want to take advantage of time sensitive discounts in order to save money on the cost of my coverage if possible

Yes

Does your contract have a disability termination clause

Yes

Not sure

Which best describes my mindset about disability insurance?

I want to get a starter policy, lock in a discount if I can. I will check back in a couple years to make adjustments if my income increases

I want to get the biggest amount of coverage possible and fully protect my income

I want something in the middle of the two options mentioned above

I don’t want to protect my income at this time and will go without a paycheck if I get sick/hurt

I would like more information on the following:

Any additional information needed?

Life Insurance

Liability Insurance

Health Insurance

Student Loans

Nothing Additional

*Disclaimer- To help us better understand who you are, where you are in life, and where you're headed, we kindly ask that you complete our intake form. Your responses are essential to the planning process and will allow us to make the most of your upcoming meeting. The more insight you provide, the more effectively we can support you. The form should only take a few minutes, and we’re looking forward to connecting with you soon!

Anything we need to know?

Any specific questions or concerns you would like to address during your consultation?

Please upload any documents you want to discuss during your consultation

Drop files here or

Max. file size: 8 MB.

TPVS Intake Form

Disclaimer

Tell us a little bit about you

Tell us about your work

Where do you live

What are your future plans?

Income

Income

Student Loans and Related Information

Tell us about your work

How can we help you today?

Annual income

Do you have any current coverage?

Health History

Disability Insurance Policy Preferences

I would like more information on the following:

Anything we need to know?