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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

Thank you for reaching out to us regarding your pet’s eyes.

Does your pet need to see the veterinary ophthalmologist? No problem! Please fill out the below form and our team will get back to you ASAP to book an appointment!
You do not need a referral from your primary care veterinarian, however, if you were previously seen there for your ocular concern, please request to have your pet’s file (including their medical history) sent over to us before your appointment. It can be helpful to know what your vet suspected was the concern and /or what medications were prescribed, etc.

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 the names, eye, and frequencies for any eye medications your pet is currently taking

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?

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

Click or drag a file to this area 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

Click or drag a file to this area to upload.

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

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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.

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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
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? *

Name

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