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New Patient Form
Though not strictly required, we encourage new clients to have their regular veterinarian send us a referral including your pet’s medical history, recent labwork, and current treatments.
Questions about your first visit? Check out our
New Patient Guide
or feel free to
contact us
.
Owner Information
Owner Names
*
First
Last
First
Last
Address
*
Street Address
Address Line 2
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State
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Armed Forces Americas
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ZIP Code
Primary Phone
*
Secondary Phone
Email
We will not share or sell your email address. It will only be used for important communications about appointments, etc.
Is the owner the primary caregiver of the pet?
*
Yes
No
How did you hear about us?
Referred by Veterinarian
Online Search
ACVO website
Pet Information and History of Problem
Pet's Name
*
What type of animal is your pet?
*
Dog
Cat
Sex
*
Male
Female
Breed
*
Spayed/Neutered?
*
Yes
No
Date of Birth or Approximate Age
*
Color
*
What lead you to believe your pet has an eye problem?
*
Loss of vision
Eye discharge
Change of eye color
Holding eye(s) closed
Primary veterinarian noticed a problem
Other
Please describe what lead you to believe your pet has an eye problem.
How long has your pet had an issue with his/her eye(s)?
*
Please be as specific as possible.
Which eye is affected?
*
Right
Left
Both
Has the affected eye changed since the problem first started?
*
Yes
No
If YES, please describe how it has changed.
Are you currently or have you used medications for this problem?
*
Yes
No
If YES, please indicate what medications, the dose, and frequency of each.
How well do you believe your pet is seeing right now?
*
Excellently, no apparent problems.
Poor vision, especially in DIM light or DARK conditions.
Poor vision, especially in BRIGHT light.
Poor vision in regard to NEAR objects.
Poor vision in regard to FAR objects.
Poor vision in regard to MOVING objects.
Poor vision in regard to STATIONARY objects.
Poor vision on all occasions.
No vision- my pet does not appear to see anything.
Do you feel your pet sees well in familiar surroundings?
*
Yes
No
Do you feel your pet sees well in strange surroundings?
*
Yes
No
Does your pet currently have any other illnesses, or has he/she had other illnesses in the past?
*
Yes
No
If YES, please list your pet's conditions.
Is your pet receiving any medications/supplements currently aside from treatments pertaining to the eye(s)?
*
Yes
No
Please list medication/supplement name, dosage, and frequency of administration.
Does your pet have any known allergies?
Yes
No
If YES, please list.
Has your pet ever had a reaction to sedatives or anesthesia?
*
Yes
No
If YES please list the medication(s).
Is your pet consuming water and food normally?
*
Yes
No
Is your pet urinating more frequently than normal?
*
Yes
No
Primary Veterinarian's Name
Clinic Name
Clinic Phone
Appointment Information
Do you have an appointment scheduled at our office?
*
Yes
No
What date is your appointment?
I, owner of the above mentioned patient, give Veterinary Ophthalmology Services permission to obtain my pet’s medical records from my primary care veterinarian.
*
Yes
No
PLEASE NOTE - IF YOU ARE NOT TAKEN TO A CONFIRMATION PAGE ONCE YOU HIT SUBMIT, YOUR FORM HAS NOT BEEN SUBMITTED. PLEASE CHECK THAT YOU HAVEN'T MISSED A QUESTION. THANK YOU!
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More
Patients
New Patient Form
New Patient Guide
Surgery Guide
Responsible Pet Ownership
FAQ
Vets & Techs
Online Referral Form
Resources for Referring Vets
Employment & Education
Information
Ophthalmic Diseases
Resources for Pet Owners
Medications
Medication Refill Form
Medication Guide