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
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Email
Referring Veterinarian
Appointment Location
Pet Information
Name
Species

Other
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
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?
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?
Please describe the discharge
Rubbing at eyes?
Which eye(s) is (are) involved?
Squinting?
Which eye(s) is (are) involved?
Cloudiness
Which eye(s) is (are) involved?
Redness?
Which eye(s) is (are) involved?
Vision Loss/Trouble Seeing?
Which eye(s) is (are) involved?
Which was first?
Worse during day or night?
Please describe the extent and duration of vision loss
Is your pet currently taking any medication? (including preventatives like heartworm, flea and tick medications)
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?
Please describe
Have you noticed any changes in urination habits?
Please describe
Does your pet have accidents in the house?
Does your pet spend most of its time indoors or outdoors?
Do you have small children in the household?
Do you have other pets in the household?
Please list type and age of other pets in the household
Do other pets in the household have similar eye problems?
Please describe
Do other pets in the household have persistent medical issues?
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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