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

Invalid Input

Pet Owner Information

First Name(*)

Invalid Input

Last Name(*)

Please type your full name.

Spouse/ Partner/ Other Agents

Invalid Input

Street Address(*)

Invalid Input

City(*)

Invalid Input

State & Zip(*)

Invalid Input

Home Phone

Invalid Input

Work Phone

Invalid Input

Cell Phone

Invalid Input

Occupation

Invalid Input

Drivers License

Invalid Input

E-mail(*)

Invalid email address.

Primary Veterinarian/ Clinic(*)

Invalid Input

Please Tell Us About Your Pet(s)

Pet Name(*)

Invalid Input

Pet Approximate Birth Date?

Invalid Input

Cat/ Dog/ Other(*)

Invalid Input

Breed(*)

Invalid Input

Color(*)

Invalid Input

Sex(*)

Invalid Input

Spayed/ Neutered(*)

Invalid Input

General Temperament?(*)

Nervous Aggressive Sweet

Invalid Input

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

Invalid Input

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

No Yes

Invalid Input

Pet Name

Invalid Input

Pet Approximate Birth Date?

Invalid Input

Cat/ Dog/ Other

Invalid Input

Breed

Invalid Input

Color

Invalid Input

Sex

Invalid Input

Spayed/ Neutered

Invalid Input

General Temperament?(*)

Nervous Aggressive Sweet

Invalid Input

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

Invalid Input

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:  

- 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.

Invalid Input

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

I agree

You must click "I Agree"