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New Patient Questionnaire

Please fill out this form as completely and accurately as possible so we can get to know your pet before their visit.

Effective September 1, 2024 we will be charging a cancellation fee of $150. We reserve your appointment time for you and require 48 hours notice for any changes to your appointment.

New Patient Questionnaire Form

Does your pet need to see the veterinary ophthalmologist? No problem!

Please fill out the information below and a member of our team will be in contact ASAP to book an appointment once it has been received. *This information is required in order to book your visit to the clinic. A referral from your primary care veterinarian is NOT REQUIRED to be seen at True North.

Also feel free to schedule a non-urgent new patient exam online using PetsApp. Click the “Book an appointment” icon in the bottom right corner to book an appointment online.

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Pet's Name *

Email *

Pet's Species *

Pet's Breed *

Pet's Coat Color *

Sex/Gender *

Female Intact
Female Spayed
Male Intact
Male Neutered

Pet's Date of Birth (or Approximate Age) *

Which eye(s) is (are) affected?

Right
Left
Both
Unsure

What changes have you noted at home? Please check all that apply.

Squinting
Rubbing or pawing at eyes
Light Sensitivity
Third eyelid elevation
Increased tearing (watery discharge)
Increased mucoid discharge (beige/gray)
Increased yellow or green discharge
Redness
Cloudiness
Other change to the color of the eyes
Mass affecting eyelid
Change in the position of the eye
Bulging of the eye
Vision loss
Other

Please indicate

Has your primary care vet made a diagnosis for your pet’s eye(s)? If yes, please list.

Approximately what date did you first note signs?

Has your pet had any prior procedures or surgery for their eye? If so, when?

Please list any eye medications being given. Include the medication name and concentration, which eye the medication is going in and how many times a day the med is being given:

Does your pet have any other ongoing systemic/whole body health concerns?

Please list any oral or other medications your pet is currently receiving

Does your pet have any significant travel history to locations outside of Manitoba?

Is your pet up to date on their vaccines and deworming?

Can your pet receive beef, chicken or pork flavored treats and medications?

Does your pet have any food or drug allergies?

Is there anything else we should be aware of with regards to your pet? Ie. anxious, rambunctious, dog aggressive, careful when lifting, etc.

Do you think that your pet is able to sit perfectly still while a veterinarian is within close range to their face?

If your answer is no, please contact your primary care veterinarian to discuss calming medications to help facilitate a stress-free visit. This may also be recommended if your pet potentially qualifies for minor procedures within the same visit (sometimes possible)

Is there anything else you would like us to know?

Who is your primary care vet clinic? *

How did you hear about us?

Please list how you heard about us!

Please attach any pictures you may have of your pet’s eyes.

Drag & Drop Files, Choose Files to Upload

If you would like to include one, please attach a picture of your pet (face or close up whole pet) to include as part of your pet’s profile in the True North records system

Drag & Drop Files, Choose Files to Upload

Thanks so much! We can’t wait to meet you and your pet!

IF YOU HAVE BEEN SEEN FOR AN EYE CONCERN AT YOUR REGULAR CLINIC PLEASE REQUEST THE FILE BE SENT OVER TO TRUE NORTH BEFORE YOUR VISIT. This will allow our team to have all the medications, lab results, initial veterinary findings prior to your visit and MAY HELP PREVENT REPEATING MEDICATIONS OR LAB WORK.

Click here to have a member of our team reach out to book an appointment.

Book a New Patient exam Book a recheck exam

Click here to schedule your own appointment online.

PetsApp booking options

Ready to Visit?

Located in the heart of Canada, we proudly serve the pets of Manitoba and beyond. We look forward to meeting you and your pet.

Request An Appointment

Follow True North Veterinary Eye Care

Questions?

Get in touch! We look forward to hearing from you.

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Contact Information

Phone: 431-932-TRUE (8783)
Fax: 204-201-2742
Email: hello@truenorthveteye.com

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Location

75 Henlow Bay
Winnipeg, MB, R3Y 1G4

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Hours

Mon – Thurs: 8 am – 5 pm
Fri – Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

Phone

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We proudly serve the pets of Manitoba, Saskatchewan, Ontario, North Dakota and beyond.