New Client/Patient Form

Appointment Date and Time*

DateHourMinutesAM/PM Option

Primary Name on Account*

Secondary Name on Account

View our Appointment Policies (Opens in a new tab) https://www.eye-vet.com/new-client-information/apptinfo/

Appointment Confirmation (If printing & bringing form with you - please confirm by call, text or email.)

By checking this box, I CONFIRM my appointment and agree to the office's appointment cancellation policies.I DO NOT confirm my appointment at this time. (If we do not get a confirmation within 24 hours of your appointment, we may have to cancel to allow another patient to be seen.)

Primary Phone Number*

Area CodePhone Number

Secondary Phone Number

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Are you able to receive text messages? (you may select multiple)

NoPrimary phoneSecondary phone

Preferred method(s) for reminders*

Phone- CallPhone- TextEmailNo preference

Have you been here before with another pet?*

YesNo

Referring Hospital

Referring Doctor

Authorization to share your pet's information with your veterinarian:

YES- I authorize the Animal Ophthalmology Center to share information about my pet to the veterinarian listed above AND any veterinarian that may contact us needing information (This can save time should an emergency arise)YES- I authorize the Animal Ophthalmology Center to share information for my pet ONLY to the veterinarian listed on this form.NO- I do NOT authorize The Animal Ophthalmology Center to share discharge information with any veterinarian.

By law, we cannot share your pet's information with anyone not listed on this form. Please list other parties that you would like us to share your pet's information with here: (This includes anyone, besides you, that may bring your pet in for care)

The Animal Ophthalmology Center is dedicated to education, especially to aid our clients, staff and other professionals understand eye related conditions. Photographs are an invaluable tool. Please choose one of the following options:

I authorize the Animal Ophthalmology Center to take photos of my pet. I grant The Animal Ophthalmology Center, its representatives, employees, the right to take photos of my pet, and to copyright, use, and publish the same in print and/or electronically. The Animal Ophthalmology Center may use such photos of my pet for any lawful purpose. Including for such purposes as publicity, illustration, advertising and web content.The Animal Ophthalmology Center MAY NOT take photos of me or my pet.

Patient Name*

Patient's Date of Birth or Approximate Age

Species:*

DogCatRabbitOther

Breed*

Sex:*

Intact MaleIntact FemaleNeutered MaleSpayed Female

PLEASE inform us PRIOR to exam if your pet may become nervous with restraint or close contact so that we may have you place a muzzle. Even if your pet has never snapped at, or bitten anyone before, our exam requires us to be eye-to-eye with your pet, and can cause some pets to become nervous and/or anxious. Please understand that this is for our protection and will not harm or traumatize your pet in any way. If your pet shows ANY sign of fear or aggression (growling, showing teeth, etc) we will require a muzzle be placed to complete our exam. If you are unable to muzzle your pet when necessary, please understand that we may be unable to attempt or complete an exam.

Thank you for your cooperation and understanding!!

Patient's Temperament?*

Brief reason for exam/referral*

Is your pet Diabetic?

YesNo

If your pet is diabetic, when were they diagnosed?

List of Current Medications Including insulin if applicable:

Please include EXACT DRUG NAME, HOW IT IS GIVEN (eye drop/ointment, pills or capsules, or injection), HOW OFTEN you are using it and, if eye drops or ointment, WHICH EYE(s) you are treating. (Hit ENTER to add more medications on a new line, or separate with commas)

List of Past Medications (if applicable to current issue)

Please include EXACT DRUG NAME, HOW IT IS GIVEN (eye drop/ointment, pills or capsules, or injection), HOW OFTEN you are using it and, if eye drops or ointment, WHICH EYE(s) you are treating. (Hit ENTER to add more medications on a new line, or separate with commas)

If you are not sure when choosing left or right eye, it is NOT when you are looking face to face with your pet, it is your pet's right or left side when facing the same direction as your pet.

Which eye(s) is affected*

RightLeftBothNo current eye issues

Currently, how is your pet's vision?*

Normal/no change seenAbsent (Blind)Diminished

If pet has trouble with vision, when did you first notice?

Approximation is fine.

If vision is diminished, do you notice a a difference in bright vs. dim light?

No differenceMore difficulty in dim light (Night lights may help)More difficulty in bright light (Pet may hesitate when going outside into bright sunlight)

If pet is blind, when they were first losing vision, did you notice a difference in bright vs. dim light?

No differenceMore difficulty in dim light (Night lights may have helped)More difficulty in bright light (Pet may have hesitated when going outside into bright sunlight)

If your pet is visually impaired, over what period of time did this change occur?

Suddenly (1-3 days)Gradually (over weeks to months)Very gradually (Over years)Pet has always had trouble with vision

Have you noticed a color change to the eye(s)? If yes, please describe.

Have you noticed a change in pupil size? If yes, please describe. (Which eye, larger, smaller, etc.)

You may check multiple boxes for the following questions.

Does your pet squint or partially hold their eye(s) shut?

Right eyeLeft eyeNeither eye/not seenOther

Does your pet rub their eye(s)? (Either with their paw or rubbing on floor/furniture)

Right eyeLeft eyeNeither eye/not seenOther

Have you noted a discharge in either eye?

Right eyeLeft eyeNeither eye/not seenOther

If yes, please describe the discharge:

(e.g. thick/viscous, clear/watery, white/grey, yellow/green, rust/brown/black, crusty)

For the next few questions, have there been any changes in the following habits in the past SIX MONTHS?

Have you seen any change in your pet's appetite (increased or decreased hunger)?

IncreasedDecreasedNo change seen

Has your pet had any (unplanned) change in their weight?

IncreasedDecreasedNo change seen

Have there been any changes in the amount your pet drinks?

IncreasedDecreasedNo change seen

Have there been any changes in the amount and/or frequency of urination?

IncreasedDecreasedNo change seen

Is your pet on flea and/or tick prevention?

YesNoUnknown

Have you seen any fleas or ticks on your pet in the past 6 months?

YesNoUnknown

Does your pet ever catch/eat small rodents such as mice or rats?

YesNoUnknown

Does your pet ever drink from standing water such as a lake, pond, or creek?

YesNoUnknown

Does your pet travel with you anywhere? (certain diseases are prominent in different areas of the state and country) If yes, Please state where your pet has traveled in the past year.

The next two questions apply to DOGS only. Leave blank or check "not applicable" for other pets.

1.Does your dog ever eat cat feces either from a household cat litter box or cat feces found outside?

2. Does your dog play aggressively with toys by shaking them back and forth rapidly? (Toy killing behavior)

YesNoUnknownNot applicable

The next four questions apply to CATS only. Leave blank or check "not applicable" for other pets.

1. For cats, where do they spend their time?

IndoorIndoor/OutdoorOutdoorNot applicable

2. Do you have multiple cats in your house?

YesNoNot applicable

3. If you have multiple cats, has the patient been with your other cat(s) for one month or more?

Yes, sharing the same areas.Yes, in the same house but in separate areas in the house.NoNot applicable

4. Has your cat been tested for Feline Leukemia (FeLV) and/or Feline Immunodeficiancy Virus (FIV)?

If you are not sure, enter "Unknown". If they were tested, please enter the test result and an approximate date when they were tested. (e.g. FeLV = neg, FIV=positive. Tested 5 years ago.)

Has your pet ever been diagnosed with any other health issues? (pancreatitis, heart disease, liver issues, ear disease, seizures, skin/allergies, etc) PLEASE LIST ALL BELOW

Is current lab work available? (performed within the last 2 months)

YesNoUnknown

Has your pet ever had any complications or concerns with general anesthesia or recovery from general anesthesia before? If yes, please describe.

Any additional notes or concerns

By submitting this form you agree to the following:

*PAYMENT IN FULL IS EXPECTED UPON COMPLETION OF THE VISIT*

-We accept Cash, Check, Visa®, MasterCard®, American Express® or Discover Card®-CareCredit® (6 MONTH NO INTEREST ON ALL AMOUNTS over $200 or 24-60 MONTH TERMS WITH 14.9% AMOUNTS OVER $1000. APPLY AT CareCredit.com)

Additional Policy Information:The Animal Ophthalmology Center charges a fee of $85 for clients who fail to cancel or no-show to their appointment without providing 24 hours notice. Clients who “No-Show/No Call” for their appointment WILL NOT BE RESCHEDULED FOR FUTURE APPOINTMENTS.

Release: I authorize and direct Dr. David Ramsey to diagnose, prescribe, perform minor therapeutic procedures, and that his judgment may dictate to be advisable for the patient’s well being. No warranty or guarantee has been made as to the result or care.

Signature

Today's Date

Type today's date.

Please verify that you are human*

Patient Information