Patient Registration Forms

PET PARENT INFORMATION

Please be sure to list everyone you want us to be able to discuss your pet with.
Primary Pet Parent Name*

First NameLast Name
Primary's Parent's Birthdate (not your pet's)*
Birth year must be 2002 or before
Email Address(s)*
email@email.com / additionalemail@email.com
Mobile Phone Number*
Format: (000) 000 - 0000.
Yes, you can text me.No, please email me.
Secondary Pet Parent (i.e. authorized to make medical and financial decisions for your pet)

First NameLast Name
Relationship of Secondary Pet Parent to Primary
Ex. Wife, Husband, Partner, etc.
Secondary's Email Address - for appointment communication
example@example.com
Secondary's Phone Number - for appointment communication
Format: (000) 000 - 0000 .
Primary Home Address*

Street Address

Unit, Suite or Apartment Number

CityState

Zip Code
At Integrative Ophthalmology for Pets, we always make every effort to accommodate your scheduling needs.

In return, we ask that you help us and our other patients by keeping to your scheduled appointment.

In order to provide excellent veterinary care and have sufficient time to thoroughly examine your pet, discuss their condition(s) and treatment options in detail, we ask that you arrive to your appointment on time, if not early.

LATE ARRIVALS (10 or more minutes) may need to be rescheduled if time does not allow us to squeeze in your appointment.

We will always do our best to be accommodating, however, our schedule may not always allow appointment adjustments. If you have any questions about anything you read, please feel free to call us.

Thank you for your understanding.

____________________________________

Policy regarding Last Minute Appointment Changes
- The FIRST OCCASION of a last minute appointment change, we will reschedule your pet's appointment without requiring a deposit.*
- The SECOND OCCASION will require a deposit of 50% deposit to reschedule.
- The THIRD OCCASION will required a 100% deposit to reschedule.
- NO SHOW/NO CALL: We automatically require a 50% deposit to reschedule, regardless if this is your first time.
*EXCEPTION: Initial Exam deposits are non-refundable within one business day of their pet's appointment. Another deposit will be required to reschedule last minute.

All deposits must be received by 2 business days before the appointment.
By signing below, I hereby acknowledge that I have read and understand the policies written above, instituted by Integrative Ophthalmology for Pets. I assume all responsibility for all charges incurred and understand the deposit policy and that payment is due in full at the time services are rendered.*

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PET INFORMATION, INSURANCE AND MEDICAL RECORDS
What is your Pet's Name? *
What is their LAST NAME at your vet's office, if it's different than yours?
DogCat
Sex:*
Breed:*
Ex. French Bulldog, Pug, Chihuahua, etc.
Color:*
Ex. Fawn, Brindle, Black, White, etc.
Pet's Date of Birth OR...

DayMonthYear
...Estimated Age in years or months.
Ex. 5 years old, 8 months, etc.
No.Yes.
No.Yes.
We will provide you with an itemized receipt so that you can submit it for reimbursement from your insurance company. Within a day or two of your appointment, we will also email your pet's medical records, including the diagnosis, for your records as well.

We recommend submitting both with your claim to expeditie your reimbursement.
We have partnered with Chewy.com to submit prescriptions for longterm medications. If you have an account, please provide the associated information and we will be sure to submit prescriptions for your pet at your appointment.

After your appointment, any requests for prescriptions will need to be sent to our pharmacy team via our website.
Chewy.com Email Address
Chewy.com Phone Number
Format: (000) 000-0000.
Where do you take your pet for regular check ups and vaccines?*
For clarification, please input the city or additional labeling
Is there a different place you took your pet for this current eye issue?*
For clarification, please input the city or additional labeling
Are there any other hospitals that you pet has been to within the past 5 years? If so, please list them here.
For clarification, please input the city or additional labeling
Help us recognize your pet by uploading a photo of them for their profile! (optional)

Be sure to click the upload button (next to the trash can icon) to attach the image to these forms.

*JPG, JPEG, or PNG files only.*

You'll see "Upload Complete" at the bottom of your image once you've successfully attached it.
By signing below, I hereby authorize Dr. Park-Dorner of Integrative Ophthalmology for Pets to examine, treat, and prescribe medications for the aforementioned pet and understand that no treatment is 100% guaranteed. Photographs may be used for patient records as well as for social media as untagged (unless one is provided) posts for educational and/or marketing purposes.*

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PET PARENT INFORMATION

At Integrative Ophthalmology for Pets, we always make every effort to accommodate your scheduling needs.

In return, we ask that you help us and our other patients by keeping to your scheduled appointment.

Thank you for your understanding.

Policy regarding Last Minute Appointment Changes

All deposits must be received by 2 business days before the appointment.

PET INFORMATION, INSURANCE AND MEDICAL RECORDS

Help us recognize your pet by uploading a photo of them for their profile! (optional)

OCULAR SYMPTOMS AND VISION INFORMATION

GENERAL MEDICAL INFORMATION