New Patient Form

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*

MaleFemale
Spayed/Neutered?*

YesNo
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?*

LeftRightBoth
What change(s) did you observe?*
How long have the changes been present?*
Has your pet received treatment/medications for this problem?*

YesNo
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, and if possible, also attach a current photo of your pet’s eye/eyes below. Click here for tips on how to take a clear photo of your pet's eyes.

You can upload the files (PDF) and images (JPG, PNG) below. A brief history of your pet’s eye issues can be typed in the box below if medical records are not available.
Please provide a copy of your veterinarian’s medical record pertinent to your pet’s problem below. A brief history of your pet's eye issues can be typed in the box below if medical records are not available.
File Upload

Maximum 10854 KB.
Cancelof
Relevant medical history:
Pet Owner's Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment confirmation preference:*

EmailTextPhone Call
Communication Agreement*

I agree to be contacted by Blink Veterinary Eye Specialists via the communication method selected above. Electronic communication with Blink's office is fully encrypted.
How did you hear about us?*
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 authorizeI 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
Should be Empty:

New Patient Form

Pet's Information

Please let us know the changes you have observed with your pet's eyes...

Pet Owner's Information

Referring Veterinarian

Primary Care Veterinarian (if different from above)

Consent for Care and Payment and Cancellation Policy