Appointment Request Form

Appointment Request Form

Please fill out this form to submit an appointment request. *Note: Completing this form does NOT confirm an appointment with us. We will reach out to you to schedule and confirm your appointment date/time.
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. You can upload the files (PDF) or enter/explain your pet's history by typing it in the box below.

Cancelof
Relevant medical history:
Pet Owner's Information
Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment confirmation preference:*

EmailPhone callText
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?*
Pet's Species & Breed*
i.e. Cat, Ragdoll
Referring Veterinarian
Doctor's Name
Hospital
Primary Care Veterinarian (if different from above)
Doctor's Name
Hospital
Preferred Appointment Times

Please choose 3 potential dates and times that you are available for an appointment. We will do our best to work within your selected times.
Preferred Appointments: First Choice*
Preferred Appointments: Second Choice*
Preferred Appointments: Third Choice*
First Choice*
Second Choice*
Third Choice*
What is the reason for your appointment request?*
i.e. I think my dog has cataracts
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
Please Note: By filling out this form, you do not need to also complete the New Patient Form on our For Pet Parents page. Your submission to this form will tell us everything we need to know to get you booked!
Should be Empty:

Appointment Request 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)

Preferred Appointment Times

Consent for Care and Payment and Cancellation Policy