Equine Exam Request.

Equine examinations should be scheduled through your veterinarian when possible.

To facilitate scheduling an appointment for your horse, please fill out the Equine Exam Request Form.

eyes@ofora.com
(831) 685-3321

8053 Valencia Street
Aptos, CA 95003

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Owner's Name

First

Last

Primary Phone #

Secondary Phone #

Primary Equine Veterinarian/ Clinic

Preferred Pharmacy (CVS, Walgreens, Costco, etc.; include location)

Horse's Name

Horse's Approximate Birth Date or Age

Breed

Color

Sex

Has this horse been examined by Ophthalmology for Animals in the past?

Have any of your other horses been examined by Ophthalmology for Animals in the past?

Location of Your Horse: Please include any gate codes, stall numbers, or special instructions under "Access Notes".

Street Address

Layout

City

State

Zip Code

Access Notes

Is your billing address different from the physical location of your horse?

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Please briefly explain your horse's condition and the reason of your exam request.

Current and Recent Medications

Please describe your horse's temperament. Has your horse required sedation for examinations in the past? If your horse requires special handling, please include relevant information here.

Who will be present during the appointment?

Owner
Other representative (e.g. trainer, barn manager, co-owner, etc.)

Comment or Message

Terms & Conditions of Service

I have read and agree to the Terms & Conditions of Service below.

We value your bond with your primary veterinarian. A referral to a specialist indicates your veterinarian’s concern for your pet. Your veterinarian will be provided with a report of your visit to ensure continuity of care. During your treatment with us, Ophthalmology for Animals cannot provide general veterinary care for your pet with the exception of emergency care. The ophthalmologist will inform you of prognosis and anticipated recovery time. In general, we recommend that you follow up with us for the presenting problem so we can accurately assess your pet’s progress and direct his/her recovery. In order to assure an optimum care provider-patient relationship, please comply with the following instructions: -Please arrive promptly for your appointment time. The time given is reserved just for you. -The office requires 48 HOURS notice if you cannot keep your appointment or need to reschedule an appointment. -If 48 HOUR notice is not given to cancel or reschedule, this will be considered a no show appointment. No show appointments may result in the need for an appointment deposit upon rescheduling. -Late arrival for exams (more than 10 minutes after scheduled appointment time) are considered no show appointments. Our team will make every attempt to work your pet in to the existing schedule but can not guarantee that an exam can be conducted. By checking the box above you are agreeing to the information provided and to the following statements. - I authorize Ophthalmology for Animals to request my pet’s medical records from my veterinarian and to release a report of ophthalmic findings to my veterinarian. - I allow the use of my pet’s medical information to be shared for analysis in retrospective studies that will help further the understanding and study of similar ophthalmic conditions. - I understand that payment is due when services are performed. - I understand that when scheduling an appointment, space is reserved for myself an my pet and will observe all cancellation policies. - I will provide payment via cash, check, CareCredit, Visa, MasterCard, Amex, or Discover credit card. Thank you for reviewing our office policies and trusting our team with your pet’s eye care.