 info@animaleyeclinic.com… 704-844-8664…

Home
About Us
- About Us
- Our Team
Services
Client Center
Referring Vets
- Referral Form
- Request Brochures
Contact
Call Us

Small Animal New Patient Form

START NOW

6580905-512 (1)

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

Appointment Date / Time *

Date

Time

Primary Owner's Name *

First

Last

Secondary Owner’s Name

First

Last

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Work Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone

Work Phone

Secondary Owner's Phone

Email *

Secondary Owner's Email

Pet's Name *

Breed *

Age *

Date of Birth (if known)

Weight

Sex *

Neutered male
Spayed female
Intact male
Intact female

Referring Veterinarian’s Name

Referring Veterinary Hospital *

Primary Veterinarian’s Name

(If different from above)

Primary Veterinary Hospital

(If different from above)

Which eye(s) currently has (have) the problem?

Right
Left
Both

For how long?

What is the eye problem?

Do you feel your pet is in pain?

Yes
No

If yes, please describe.

Does your pet exhibit any signs of vision loss?

Yes
No

If yes, please describe.

Does your pet have any prior eye problems?

Yes
No

If yes, please describe.

Please list current eye medications and state whether it is drops or ointment, how many times a day given, and for how long.

Does your pet have any other health problems? If yes, describe.

Does your pet have any of the following?

vomiting
diarrhea
coughing
sneezing
lethargy

If yes, please describe.

Is current lab work available?

Yes
No

If yes, please describe abnormalities.

Travel History/Other:

Please list any other medications and state whether it is drops or ointment, how many times a day given, and for how long.

Ophthalmology Exam Fees:

Ophthalmology first consultation $149
Ophthalmology recheck exam $79
Urgent to emergency consultation $249
Intraocular pressure measurement $44.50
Schirmer tear test $29.50
Fluorescein corneal stain $28.50

*We accept all major credit cards, cash, CareCredit, and Scratch Pay. We DO NOT accept checks.

Checkboxes *

I agree to the above fees associated with said service.

You may ask a team member the cost of an initial or recheck exam. Note: Pressure measurement, tear tests, and corneal stains are additional tests and not included in the initial consultation fee or future rechecks. These tests will be performed only if deemed necessary by the clinician. Please let us know if you have any questions before these tests are performed.

I have read the above statement. *

Initial here

I give consent to Animal Eye Clinic to post photos of my pet on social media. *

Yes
No

We will not post any personal information.

Appointment Cancellation Policy Agreement: If it is necessary for you to cancel or reschedule your pet's appointment, we request that you provide at least 24 hours notice. You will be asked to prepay the consultation fee when rescheduling your pet's future appointment if requested notice is not provided or you have missed your pet's prior appointment. This deposit will act as a credit toward your pet's appointment and is transferable in the event that you need to reschedule if at least 24 hours notice is provided. If less than 24 hours notice is provided or the appointment is missed, your deposit is non-refundable. Our appointments are in high demand and your early cancellation will allow for another pet to receive care. We appreciate your understanding and support. *

I have read and understand

Signature *

Clear Signature

Date *

animal eye clinic

We’re pleased to provide the highest level of eye care for our patients in a clean, relaxing, and loving environment.

w

Contact

P: 704-844-8664
E: info@animaleyeclinic.com
F: 704-844-8738



Main Office Location

2440 Plantation Center Drive
Matthews, NC 28105



Main Office Hours

Mon – Friday: 8 a.m. – 5 p.m.
Sat – Sun: Closed



Satellite Hours

By appointment only.
Contact us at 704-844-8664 to schedule your appointment.

Have a question?

Get in touch! Complete the form below and a member of our team will be in touch with you shortly. If you’re in need of immediate assistance, please contact us at 704-844-8664.

Name *

First

Last

Email *

Phone

How can we help you? *

Message

© 2024 Animal Eye Clinic | Powered by WhiskerCloud