New Patient Form – Animal Ophthalmology Clinic | Animal Eye Specialists in Dallas, Texas

CLIENT HISTORY & INFORMATION

First Name *

Last Name *

DL #

Address

Apt, suite, etc.

Country

City

State

Zip code

Mobile *

Home

Work

Employer

Referring Veterinarian

Appointment Location *

Dallas

Grapevine

Unsure

Pet Name *

Species *

Dog

Cat

Horse

Other

If Other, Specify

Breed *

Sex *

Age

Color

Neutered

Yes

Unsure

Please complete all of the following questions to the best of your knowledge. Approximate dates are acceptable. Thank you for your help.

Onset

Sudden

Gradual

When did you first notice the problem?

Describe the complaint

Is pet having discharge? *

Yes

Type of discharge?

Rubbing at eyes? *

Yes

Which eye(s) is (are) involved?

Left

Right

Both

Squinting? *

Yes

Which eye(s) is (are) involved?

Left

Right

Both

Cloudiness? *

Yes

Which eye(s) is (are) involved?

Left

Right

Both

Redness? *

Yes

Which eye(s) is (are) involved?

Left

Right

Both

Vision Problems? *

Yes

Which eye(s) is (are) involved?

Left

Right

Both

Worse during day or night? *

Day

Night

Unsure

Duration of vision loss?

Was onset gradual or acute? *

Gradual

Acute

What 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?

Left

Right

Both

If both are involved, which was first?

Left

Right

Both

If your pet has trouble seeing, describe the extent

If your pet’s vision is worse at a particular time of the day or night or in bright or dim lighting conditions, please describe

Is 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 mostly

Indoors

Outdoors

Partly in and out

Do you have small children in the household?

Yes

Do you have other pets in the household?

Yes

If yes, list other pets that are in household

Do they have similar eye problems?

Yes

Do they have other illnesses?

Yes

Describe the pet’s diet (type and amount)

Have you noted any changes in the amount of water your pet drinks?

Increased

Decreased

No change

Don’t know

If so, please describe the degree of change

If you notice any changes in urination, please describe

Does your pet have accidents in the house?

Yes

What treatment(s) has your pet received, and how long has your pet been receiving the treatment(s)?

Have the treatments helped? Please explain

When 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.

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