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.

New Patient Questionnaire Form

Thank you for reaching out to us regarding your pet’s eyes. Please fill out the New Patient Questionnaire before your pet’s first visit. In addition to this form, please make sure that you complete the following two steps:

Fill out the Appointment Request Form
Ask your primary care veterinarian to fill out the Patient Referral Form

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Layout

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

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 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?

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!

New Patient Questionnaire

New Patient Questionnaire Form

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Questions?

Contact Information

Location

Hours