Wellness Clinic Referral Form

Is this a self-referral?

Yes

No, I am a social service worker/worker

Eligibility

Anyone who does not have a regular veterinarian can access this service. For subsidized services, we will be working directly with local social services to identify those who need assistance caring for their animals. Pet families who receive a government subsidy can also reach out to us directly to book an appointment. Proof of eligibility will be required.

Review Guidelines(Required)

I have reviewed the eligibility requirements and would like to proceed with my self-referral

Please indicate eligibility:(Required)

Ontario Disability Support Program (ODSP)

Ontario Works (OW)

Guaranteed Income Supplement (GIS)

Possess a Certificate of Indigenous Status(CIS)

No current veterinarian

Name of social service worker making referral:(Required)

First Last

Agency you are referring from:(Required)

Animal owner's name:(Required)

First Last

Animal Owner's Email:(Required)

Animal Owner's Phone Number:(Required)

Comments:

Name

This field is for validation purposes and should be left unchanged.

Eligibility

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