Name Of Owner *

First

Last

Phone (Primary) *

e.g. (204)123-4567

Phone (Secondary)

Email *

Email

Confirm Email

Current Address *

First

Last

First

Last

How Many Pets Is This Appointment For? *123456

Please submit a new form for each new pet.

Name Of Pet *

Date Of Birth *

• Cat
• Male
• Female
• Dog
• Male Neutered
• Female Spayed

Breed *

Colour/Pattern

Does Your Pet Have Any Medical Conditions Or Allergies? (Please describe in detail.)

Is Your Pet On Any Medication Or Supplements? (Please list them here.)

Your Pet's Previous Regular Clinic/Hospital

Preferred Appointment Time *

• First Available
• Morning
• Afternoon

Appointment Type (Please select all that apply.) *Routine Wellness ExamRoutine Wellness ExamRecheck ExamVaccinesParasite Preventative (i.e. Ticks, Heartworm, Deworming, etc.)4Dx Plus Test (Canine Tick & Heartworm Test)FIV/FelV Test (Test For Feline Immunodeficiency Virus & Leukemia Virus)Puppy/Kitten AppointmentNon-Emergent Sick Pet ExamSkin/Ear ConsultDiabetic ConsultSecond OpinionPalliative Care ConsultEuthanasiaTelemedicineOther

Message (Please describe any concerns in detail.)

Do you permit photos to be taken of your pet and used for social media?

• YES
• NO

How Did You Hear About Us?Referred By A FriendReferred By A FriendFacebookInstagramSocial Media AdManitoba Hydro AdWord Of MouthOther

If You Selected Other, Please Specify

Submit