New Patient Form
Prior to your pet’s first appointment, please fill out the form below. If you have any questions, call or text us at 214.817.0637.
Pet's Information
Pet's Name
*
Birthdate or Estimated Age
*
Sex
*
Male
Female
Spayed/Neutered?
*
Yes
No
Species
*
Breed(s)
*
Weight
Color
*
Please let us know the changes you have observed with your pet's eyes...
Which eye(s) have you noticed having problems?
*
Left
Right
Both
What change(s) did you observe?
*
How long have the changes been present?
*
Has your pet received treatment/medications for this problem?
*
Yes
No
If so, please list the medications:
Has your pet had any drug reactions/allergies?
*
Please provide a copy of your veterinarian's medical record pertinent to your pet's problem. You can upload the files (PDF) or enter/explain your pet's history by typing it in the box below.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Relevant medical history:
Pet Owner's Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment confirmation preference:
*
Email
Text
Phone Call
How did you hear about us?
*
Please Select
Primary care veterinarian
Friend
Social media
Google
Drive by
Other
Referring Veterinarian
Doctor's Name
Hospital
Primary Care Veterinarian (if different from above)
Doctor's Name
Hospital
Consent for Care and Payment and Cancellation Policy
All fees are required to be paid in full at the completion of your visit. Blink Veterinary Eye Specialists accepts Mastercard, Visa, Discover, American Express, Care Credit, and cash. We do not accept checks.
I authorize use of my pet's first name, photographs, and clinical information on Blink Veterinary Eye Specialists' website, social media, or within informational pamphlets. Under no circumstances will my name, my personal or financial information be shared through these media sources.
*
I authorize
I do NOT authorize
I authorize that I am over eighteen years of age and I authorize Blink Veterinary Eye Specialists and its employees to assess and treat my animal listed above, and I agree to pay all fees associated with these services at the time services are rendered.
*
I authorize
At least 24 hours of notice is expected for cancellations. I understand that if I noshow or cancel with less than 24 hours notice, I may be required to pay a nonrefundable deposit in the amount of the initial exam fee cost in order to reschedule to the next available appointment.
*
I authorize
Submit
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