EYESDG - New Client Form

New Client Form

Animal Ophthalmology Clinic
Client Information
First Name*
Last Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Alternate Phone Number
Email*
Referring Veterinarian
Appointment Location*

DallasGrapevine
Pet Information
Name*
Species*

DogCatHorseOther
Breed*
Sex*
Date of Birth/Age
Color*
Please complete all of the following questions to the best of your knowledge. Approximate dates are acceptable. Thank you for your help.
Onset

SuddenGradual
When did you first notice the problem?
Describe the complaint
Is the problem worse at certain times of the year than others?
Is the problem painful or irritating to your pet?
Has your pet received any treatment for this problem previously?

YesNo
Please describe the treatment
If you know of animals related to your pet which have similar problems, how are they related?
Is the pet having discharge?*

YesNo
Please describe the discharge
Rubbing at eyes?*

YesNo
Which eye(s) is (are) involved?*

LeftRightBoth
Squinting?*

YesNo
Which eye(s) is (are) involved?*

LeftRightBoth
Cloudiness*

YesNo
Which eye(s) is (are) involved?*

LeftRightBoth
Redness?*

YesNo
Which eye(s) is (are) involved?*

LeftRightBoth
Vision Loss/Trouble Seeing?*

YesNo
Which eye(s) is (are) involved?*

LeftRightBoth
Which was first?*

LeftRightSame time
Worse during day or night?*

DayNightBothNeitherUnsure
Please describe the extent and duration of vision loss
Is your pet currently taking any medication? (including preventatives like heartworm, flea and tick medications)*

YesNo
Please list your pet's current medications (including preventatives)*
Date of last vaccination*
Date of last bloodwork
Please list previous surgeries:
List any reactions to medications:
Does your pet have any other medical problems?
Describe the pet’s diet (type and amount)
Have you noted any changes in the amount of water your pet drinks?

IncreasedDecreasedNo changeUnsure
Please describe
Have you noticed any changes in urination habits?

YesNo
Please describe
Does your pet have accidents in the house?

YesNo
Does your pet spend most of its time indoors or outdoors?

IndoorsOutdoorsIndoors mostly with some outdoor timeOutdoors mostly with some indoor timeAbout the same
Do you have small children in the household?

YesNo
Do you have other pets in the household?

YesNo
Please list type and age of other pets in the household
Do other pets in the household have similar eye problems?

YesNo
Please describe
Do other pets in the household have persistent medical issues?

YesNo
Please describe
Explanation of Fees
Medical fees, in all fields of medicine, have been rising because of increased cost. The fees for services are usual and customary charges for the kind of specialized services rendered, and are comparable to those of other veterinary ophthalmologists across the United States. Fees are payable when services are rendered. Payment can be made in cash, check or by Visa, Mastercard, Discover, American Express, or Care Credit.
I understand and agree*
Signature*

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New Client Form

Client Information

Pet Information