Primary Care Application Form

One of the following must be submitted with this application as verification of income:

Copy of most recent Notice of Assessment identifying annual income of all family members
Copy of social assistance (EIA) budget letter
Copy of monthly statement of income from CPP Disability including the income verification

Please email to: [email protected]

Name

First

Last

Address

Apartment/Suite/Unit Number (If Applicable)

Postal Code

City

Province

Phone

Adults in Home

Children in Home

Yearly gross income of all spouses, partners, and/or guardians in the home combined:

Social Assistance (EIA) case number (6-digit number) if applicable:

Pet's Name

Type of Animal

Breed if Applicable:

Animal Gender:

Is Animal Spayed/Neutered?

Age in Years:

If under 1 year old, how many months old?

Hair Length:

Primary Hair Colour:

Secondary Hair Colour:

Does your pet have any stripes or distinguishing features? (i.e. Tabby)

Has your pet ever been to a veterinarian? If yes, which clinic did you visit and when?

Has your pet had any vaccinations? Which ones? When were they administered?

Please provide a summary of what services you are requiring (i.e., annual exam, vaccinations, deworming)

Do you have any additional medical concerns that you would like to address with the veterinarian? If yes, please explain (i.e., lumps/bumps, bad breath, ear/eye issues):

Is your pet nervous with new people?

Yes

Does your pet have a history of biting?

Yes

Does your animal not like a certain type of handling? (ex cat being picked up, ears or feet being touched)

Yes

If you selected "Yes" on previous question, please explain:

Does your dog need a muzzle for vet visit?

Yes

Not Applicable (Not bringing in Dog)

If you are human, leave this field blank.