Barrie Animal Hospital Eye Appointment Form

Eye Appointment Form

This form is designed to help our team gather important information about your pet's current status for your upcoming visit with our team!
What is your pet's name?*
What is your name?*
Please describe the first time symptoms started*
Which eye(s) is affected?*

Right eyeLeft eyeBoth eyes
If there is discharge, what colour is it?
Is there redness?*

YesNo
Is your pet squinting?*

YesNo
Is your pet pawing at his/her face?*

YesNo
Is there any apparent swelling around the eye or other areas of the face?*

YesNo
Is your pet tilting their head?*

YesNo
Have you seen any incidents that may caused trauma to your pet's eye(s)? *
Have you started your pet on any medications? If so, what medications and what dosage?*
Please rate your pet's itchiness *
Score from 1-10, 1 being not itchy at all, 10 being extremely itchy
Have you noticed any changes in your pet's personality or behaviours?*

YesNo
Is your pet on flea/tick/heartworm prevention currently?*

YesNo
When was the last dose of flea/tick and or heartworm prevention given?*

MonthDayYear
Date
What diet is your pet currently eating?*
Please note canned and dry food
Please upload pictures of any food, treats, medications or supplements your pet is currently taking:

Cancelof
Did we forget something?
Please list any questions/problems/concerns that you would like addressed
Thank you for answering all of our questions, it helps us to deliver a more thorough and comprehensive experience for you and your pet!
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Eye Appointment Form