Ophthalmology For Animals Welcomes New Patients

New Patients Paperwork

We are excited to welcome you and your pets as new patients at Ophthalmology For Animals, Inc.! Please fill our our New Patient Paperwork below.

Appointment Status(*)

Yes, I have an appointment scheduled
No, I need to schedule an appointment (Credit Card required to finalize appointment)

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Pet Owner Information

First Name(*)

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Last Name(*)

Please type your full name.

Spouse/ Partner/ Other Agents

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Street Address(*)

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City(*)

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State & Zip(*)

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Home Phone

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Work Phone

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Cell Phone

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Occupation

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Drivers License

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E-mail(*)

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Primary Veterinarian/ Clinic(*)

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Please Tell Us About Your Pet(s)

Pet Name(*)

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Pet Approximate Birth Date?

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Cat/ Dog/ Other(*)

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Breed(*)

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Color(*)

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Sex(*)

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Spayed/ Neutered(*)

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General Temperament?(*)

Nervous Aggressive Sweet

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Please briefly explain your pet's condition and the reason for your visit.(*)

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

No Yes

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Pet Name

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Pet Approximate Birth Date?

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Cat/ Dog/ Other

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Breed

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Color

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Sex

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Spayed/ Neutered

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General Temperament?(*)

Nervous Aggressive Sweet

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

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Terms & Conditions

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:  

- All New Patient Appointments require a $250 deposit at the time of booking. This deposit will be applied towards the initial exam cost on the day of the appointment. In order for an appointment deposit to be transferred to another date or refunded, the appointment must be canceled or rescheduled at least 48 HOURS prior to the initial appointment. Cancellations made less than 48 HOURS before the appointment will not receive a deposit refund. Rescheduled appointments made less than 48 HOURS before the appointment will require an additional deposit. 
   
- Please arrive promptly for your appointment time.  The time given is reserved just for you. 

- The office requires 24HOUR 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 a $100 no show fee which must be paid before another appointment is scheduled.

- Late arrival for exams (more than 10 minutes after scheduled appointment time) will result in a cancellation/no show fee. 

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 also 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, the undersigned owner or agent of the owner, understand that payment is expected when services are performed. I understand and will observe all cancellation policies and agree to pay any cancellation fees that occur if such policies are not abided by. I will provide payment via cash, check, CareCredit, Visa, MasterCard, Amex, or Discover credit card.

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By checking "I Agree" you are agreeing to all Terms & Conditions detailed above(*)

I agree

You must click "I Agree"

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