Ophthalmology Consult Request
I understand that this form does not create an appointment and that an Ophthalmology team member will contact me to schedule.
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I understand
How would you like us to contact you to confirm and schedule your pet's ophthalmology consultation?
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Phone
Email
Your Name
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First Name
Last Name
Your Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email
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example@example.com
Your Phone Number
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Please enter a valid phone number.
Pet's Information
Pets Name
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Breed
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Sex
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Male
Female
Is your pet spayed/neutered?
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Yes.
No.
Species
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Canine
Feline
Other
If Other, please specify
Pet's Age
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Pet's Birthday
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Month
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Day
Year
Date
Your Primary Care Veterinarian's Information
Primary Care Hospital Name
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Hospital Phone
Please enter a valid phone number.
Primary Care Veterinarian's Name
Who referred your pet to us?
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Self, Primary Care Veterinarian, Google search, Social media, Friend...
Why are you requesting an ophthalmology evaluation for your pet?
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Please give a brief history of your concerns.
Are you requesting a specific doctor?
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No. First available.
Yes. A specific doctor.
Doctor's name
Preferred days and locations for your pet's consult. Select all that apply.
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Monday - North Haven
Friday - North Haven
Tuesday - North Haven
Tuesday - Guilford
Wednesday - North Haven
Wednesday - Guilford
Thursday - North Haven
Please verify that you are human
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Submit
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