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Registration Form for Orangeville Wellness clinic (February 21st and 22nd)
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This field is for validation purposes and should be left unchanged.
Animal Owner's Name
(Required)
First
Last
Animal Owner's Address
(Required)
Street Address
Address Line 2
City
Province
ZIP / Postal Code
Daytime Phone Number
(Required)
Secondary Phone Number
Email
(Required)
Species
(Required)
Cat
Dog
Animal's Name
(Required)
Animal's Age
(Required)
Please indicate your animals age with a number, followed by if it is months or years
Breed
(Required)
Sex
(Required)
Male
Male Neutered
Female
Female Spayed
Unsure
Please advise us of any medical conditions past or present (seizures, skin condition, heart murmur etc ..)
(Required)
If your pet has no on going medical conditions you can indicate none in the above field.
Please advise us of any medications or suplimentations your pet is currently taking (eg. Heartworm meds, antibiotics, ear meds, probiotics) and the frequency that they are given (eg. Daily, every month, only when needed).
(Required)
If your pet is currently not on any medications indicate as none in the above field.
Services requested
(Required)
Exam Full price = $60 Subsidized = $30
*Rabies Full price = $33 Subsidized = $17
*DA2PP Full price = $33 Subsidized = $17
*Lepto Full price = $33 Subsidized = $17
*Bordetella Full price = $33 Subsidized = $17
Microchip Full price = $36 Subsidized = $18
*Exam included. Exam charged for general wellness exams with no vaccines. Any medications recommended for your pet may be paid for at the conclusion of the exam.
Services requested
(Required)
Exam Full price = $60 Subsidized = $30
*Rabies Full price = $33 Subsidized = $17
*FVRCP Full price = $33 Subsidized = $17
*FeLV Full price = $33 Subsidized = $17
Microchip Full price = $36 Subsidized = $18
*Exam included. Exam charged for general wellness exams with no vaccines. Any medications recommended for your pet may be paid for at the conclusion of the exam.
Please provide us with the name of your Regular Veterinarian or Veterinary Clinic
(Required)
If you do not have a regular veterinary clinic please indicate as none in the above field.
Does your cat meet the "ideal" body condition as per the charts linked below?
(Required)
Yes
No
Unsure
Does your dog meet the "ideal" body condition as per the charts linked below?
(Required)
Yes
No
Unsure
Do you receive government subsidy, or have an Indigenous status card?
(Required)
Yes
No
Upload proof of government subsidy or indigenous status
(Required)
Max. file size: 50 MB.
Any of the following qualifies for subsidy: CPP-D (Canada Pension Plan), ODSP (Ontario Disability Supplement Program), OW (Ontario Works), Indigenous status, GIS (Guaranteed Income Supplement), OAS (Old Age Security). Please upload any form/statement/screenshot of the above with your full name and address visible.
Consent
(Required)
I acknowledge that this appointment request is for our MASH-style mobile Wellness clinic in Orangeville