Small Animal New Patient Form

Name: Animal Eye Clinic
Address: 2440 Plantation Center Drive, Matthews, NC, 28105, United States
Telephone: 704-844-8664
Price range: $

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New Patients

Please fill out the form below if you have a small animal before your first visit. If you do not have an appointment yet, please call us at 704-844-8664.

Animal Eye Clinic Small Animal New Patient Form

Step 1 of 2

Owner's Name *

First

Last

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Phone Number *

Owner’s Date of Birth

Occupation

Additional Owner’s Name

First

Last

Email Address

Phone Number

Pet's Name *

Age or Date of Birth *

Breed *

Sex *

Male Neutered
Male
Female Spayed
Female

Referring Veterinarian’s Name and Hospital Name

Primary Veterinarian’s Name and Hospital Name (if different)

Please Initial & Sign below:

Cancellation Policy: *

We require 24-hour notice for rescheduling or cancellation of appointments. Less than 24-hour notice may be subject to a cancellation fee.

Payment Policy *

Payment is due at time of service. We accept all major credit cards, cash, Scratch Pay, and CareCredit (with owner of the card present). *We do NOT accept checks.

Social Media Consent *

I do give consent to post photos of my pet on social media.
I do not give consent to post photos of my pet on social media.

Photos are used for educational purposes only, no personal information will be disclosed.

Treatment Consent *

I have read, understand, and give consent for treatment by completing this form.

Signature *

Clear Signature

Date *

Small Animal New Patient Form

New Patients

Animal Eye Clinic Small Animal New Patient Form

Please Initial & Sign below:

Current Eye Medications

Ophthalmology Exam Fees:

Diagnostic Testing:

Contact

Main Office Location

Main Office Hours

Satellite Hours

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