If you are human, leave this field blank.CLIENT HISTORY & INFORMATIONFirst Name *Last Name *DL #AddressApt, suite, etc.CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern 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(Nederland)+31New Caledonia (Nouvelle-Calédonie)+687New Zealand+64Nicaragua+505Niger (Nijar)+227Nigeria+234Niue+683Norfolk Island+672North Korea (조선 민주주의 인민 공화국)+850Northern Mariana Islands+1670Norway (Norge)+47Oman (عُمان)+968Pakistan (پاکستان)+92Palau+680Palestine (فلسطين)+970Panama (Panamá)+507Papua New Guinea+675Paraguay+595Peru (Perú)+51Philippines+63Poland (Polska)+48Portugal+351Puerto Rico+1Qatar (قطر)+974Réunion (La Réunion)+262Romania (România)+40Russia (Россия)+7Rwanda+250Saint Barthélemy (Saint-Barthélemy)+590Saint Helena+290Saint Kitts and Nevis+1869Saint Lucia+1758Saint Martin (Saint-Martin (partie française))+590Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508Saint Vincent and the Grenadines+1784Samoa+685San Marino+378São Tomé and Príncipe (São Tomé e Príncipe)+239Saudi Arabia (المملكة العربية السعودية)+966Senegal (Sénégal)+221Serbia (Србија)+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1721Slovakia (Slovensko)+421Slovenia (Slovenija)+386Solomon Islands+677Somalia (Soomaaliya)+252South Africa+27South Korea (대한민국)+82South Sudan (جنوب السودان)+211Spain (España)+34Sri Lanka (ශ්රී ලංකාව)+94Sudan (السودان)+249Suriname+597Swaziland+268Sweden (Sverige)+46Switzerland (Schweiz)+41Syria (سوريا)+963Taiwan (台灣)+886Tajikistan+992Tanzania+255Thailand (ไทย)+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad and Tobago+1868Tunisia (تونس)+216Turkey (Türkiye)+90Turkmenistan+993Turks and Caicos Islands+1649Tuvalu+688U.S. Virgin Islands+1340Uganda+256Ukraine (Україна)+380United Arab Emirates (الإمارات العربية المتحدة)+971United Kingdom+44United States+1Uruguay+598Uzbekistan (Oʻzbekiston)+998Vanuatu+678Vatican City (Città del Vaticano)+39Venezuela+58Vietnam (Việt Nam)+84Wallis and Futuna+681Yemen (اليمن)+967Zambia+260Zimbabwe+263EmailEmployerReferring VeterinarianAppointment Location *DallasGrapevineUnsurePet Name *Species *DogCatHorseOtherIf Other, SpecifyBreed *Sex *AgeColorNeuteredYesNoUnsurePlease complete all of the following questions to the best of your knowledge. Approximate dates are acceptable. Thank you for your help. OnsetSuddenGradualWhen did you first notice the problem?Describe the complaintIs pet having discharge? *YesNoType of discharge?Rubbing at eyes? *YesNoWhich eye(s) is (are) involved?LeftRightBothSquinting? *YesNoWhich eye(s) is (are) involved?LeftRightBothCloudiness? *YesNoWhich eye(s) is (are) involved?LeftRightBothRedness? *YesNoWhich eye(s) is (are) involved?LeftRightBothVision Problems? *YesNoWhich eye(s) is (are) involved?LeftRightBothWorse during day or night? *DayNightUnsureDuration of vision loss?Was onset gradual or acute? *GradualAcuteWhat heartworm preventative is your pet taking?Date of last vaccination: *Date of last bloodwork: *Please list previous surgeries:List any reactions to medications:Other health problems:Which eye(s) is (are) involved?LeftRightBothIf both are involved, which was first?LeftRightBothIf your pet has trouble seeing, describe the extentIf your pet’s vision is worse at a particular time of the day or night or in bright or dim lighting conditions, please describeIs the problem worse at certain times of the year than others?Is the problem painful or irritating to your pet?If you know of animals related to your pet which have similar problems, how are they related?Is your pet mostlyIndoorsOutdoorsPartly in and outDo you have small children in the household?YesNoDo you have other pets in the household?YesNoIf yes, list other pets that are in householdDo they have similar eye problems?YesNoDo they have other illnesses?YesNoDescribe the pet’s diet (type and amount)Have you noted any changes in the amount of water your pet drinks?IncreasedDecreasedNo changeDon’t knowIf so, please describe the degree of changeIf you notice any changes in urination, please describeDoes your pet have accidents in the house?YesNoWhat treatment(s) has your pet received, and how long has your pet been receiving the treatment(s)?Have the treatments helped? Please explainWhen did your pet last receive treatment and what was it?Does your pet have any other medical problems?Does your pet show any other abnormal signs?Explanation of Fees *Medical fees, in all fields of medicine, have been rising because of increased cost. The fees for services are usual and customary charges for the kind of specialized services rendered, and are comparable to those of other veterinary ophthalmologists across the United States. Fees are payable when services are rendered. Payment can be made in cash, check or by Visa, Mastercard, Discover, American Express, or Care Credit.I understand and agreeCaptcha *reCAPTCHA is required.Submit