Service Requested

In-Home Nurse Aid Reservation for Services Requested** (**services requested are extra)
In-Store Nurse Aid Reservation for Services Requested (**services requested are extra)
Telemedicine Nutritional Consultation
Telemedicine Wellness Consultation

Brief Description of Medical Concerns/Reason for Booking:

**1) & 2) For In-Home & In-Store Bookings please list the services requested for your pet. A Veterinary Nurse will then phone you to complete an in-take form to obtain a brief medical history on your pet before finalizing your booking. 3) For a Nutritional Consultation with a Nurse, please include in the field above what you are currently feeding your pet. 4) For a Wellness Consultation with a Veterinarian please indicate any previous or current medical condition(s) you pet has in addition to his/her current issues you need assistance with.

Desired Date for Appointment

If we are unable to accommodate your first choice, we will automatically work towards accommodating your second choice. If the second or third choice appointment spots are also full, you will receive a phone call from our Customer Care Specialist to help with this booking. NO payment will be taken until a date and time has been confirmed for your booking.

Desired Expected Time of Arrival for Appointment *

9am-11am
11am-1pm
1pm-3pm
3pm-5pm
5pm-7pm
7pm-9pm

Our traveling Nurses will phone you once they are 15-20 minutes away, BUT they will arrive at any time between your requested time period. This would be the same condition for any booked Telemedicine Consultations.

Client’s First Name

Client’s Last Name

Email

*We use your email address solely for your personal medical communications. Your email will never be used for spam nor will it be sold/given to a third party.

Phone (Canadian Only)

**We Accept Canadian Phone Numbers Only.**

If you are booking a NURSE HOME VISIT requested service, enter your FULL address info below:

**We are only able to provide Home services in Toronto and some surrounding areas in Ontario, Canada**

Pet Name

Pet Type (Species)

Dog
Cat
Other*

**PLEASE NOTE: Our Veterinarians & Nurses are NOT specialists with exotic pets. If you have another type of pet, kindly write that your pet you are seeking assistance for is for example a hamster, a lizard, a bird under the Brief Description above. Prior to processing your appointment, you will receive a phone call confirmation with one of our Customer Care Specialists to ensure you have been matched appropriately to a Veterinarian or Nurse that is able to assist you and your pet.

Breed (Optional)

Pet Gender & Condition

Male Neutered
Female Spayed
Male Intact
Female Intact

Temperament of your Pet

I don't know
Very Friendly
Can be Guarded
Very Anxious
Relaxed with any Grooming & Gentle Handling
Can be Spicy

Pet Age

Up to Date With Vaccines

I don't know
Yes
No

Pet Weight

It would be helpful to the Veterinarian & Nurse if you can obtain a weight of your pet prior to the consultation in the event medications or feeding amounts are scripted out to you. At home, you can get a weight of your pet by lifting and holding him/her over a weight scale and then subtract your weight

Pet Weight taken in Kg or Lbs (Optional)

Kgs
Lbs

Please upload any test results, medical records, or photos of your pet that you feel may be helpful to your consultation or Nurse Visit.

doc, docx, jpeg, jpg, pdf, png, xls, xlsx files are only accepted

Visa or MC Number (Optional)

We do NOT accept Visa debit, Debit or Amex

Expiry Date of Visa or MC (Optional)

Security Code (3-Digit Code on Back) (Optional)

Email money transfers (e-transfers) are also accepted. E-transfers can be sent to: services@topethealth.com using the password “Health”.

Finalize Booking **PLEASE NOTE: Dear Clients, just a gentle reminder that due to the nature of our business operation, once an appointment is booked online or over the phone, the Appointment Fee for missed, late, cancelled or rescheduled appointments will not be reimbursed.**

Please charge my credit card or accept my e-transfer to finalize my booking. I understand this fee is NON-REFUNDABLE to secure my appointment. Only provide a phone call if my requested time slot is not available.
I did NOT enter my credit card or e-transfer info. Please have a Customer Care Specialist phone me to obtain my credit card info and finalize my booking. I understand that once an appointment is finalized with a Customer Care Specialist, NON-REFUNDABLE Appointment Fees will apply.

In Home & In-Store Appointment Bookings:

Thank you for your form submission!!

Thank you for your form submission!!

Purina HA Hypoallergenic Form - Canine Canned 377g /PKGX12

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