Appointment Status

Yes, I have an appointment scheduled.
No, I need to schedule an appointment.

+ Pet Owner Information +

Your First Name

Your Last Name

Spouse / Partner / Other Agents

Street Address

Layout

City

State

Zip Code

Primary Phone #

Secondary Phone #

Occupation

Email

Primary Veterinarian / Clinic

Preferred Pharmacy (CVS, Walgreens, Costco, etc.)

Does your pet have an insurance policy?

Yes
No

If yes, please provide your pet's provider and policy number?

+ Tell us about your pet(s) +

Pet Name

Pet's Approximate Birth Date

Species (dog, cat, other)

Breed

Color

Sex

Spayed / Neutered

General Temperament

Nervous
Aggressive
Sweet

Please briefly explain your pet's condition and the reason of your visit.

Will you be bringing in a second pet during your visit?

No
Yes

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 24 HOURS notice if you cannot keep your appointment or need to reschedule an appointment.
-If 24 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.

New Patients.