Animal Eye Clinic

Fees charged reflect the quality and
value of our advanced and specialized medical and surgical services. They
reflect the degree of expertise required to diagnose and treat your pet, as
well as the cost of the diagnostic, therapeutic, and surgical equipment
utilized. Written estimates are provided for patients for which surgery and/or
advanced diagnostic procedures under sedation or general anesthesia are
recommended.  Fees are payable in
full when services are provided, in the form of a major credit card (Visa,
MasterCard, Discover, or American Express), a debit card, or a check or  cash.

DATE:___________________________
PET’S NAME:________________________________________________

OWNER
NAME:___________________________________________________________________________________

STREET:________________________________________________________________________________________

CITY:_____________________________________________  STATE:_____________  ZIP:_____________________

PHONE:
(H)___________________________
(W)_________________________
(C)__________________________

DRIVER
LICENSE #___________________________________________________________
STATE:_____________

REFERRING
CLINIC & VET:________________________________________________________________________

REFERRING CLINIC FAX:_________________________________  PHONE__________________________________

ABOUT
YOUR PET:

BREED:_____________________  COLOR:___________________
BIRTHDATE:______________
SEX:___________

SPAYED/NEUTERED?__________ WEIGHT:_________  DIABETIC?_________IMMUNIZATIONS
CURRENT?______

PLEASE
LET US KNOW THE CHANGES YOU’VE OBSERVED REGARDING YOUR PET’S EYES:

1.  WHICH EYE(S) HAVE YOU NOTICED HAVING
PROBLEMS?____________________________________________

2.  WHAT CHANGES DID YOU OBSERVE?_____________________________________________________________

______________________________________________________________________________________________

3.  HOW LONG HAVE THE CHANGES BEEN
PRESENT?_________________________________________________

4.  HAS YOUR PET RECEIVED
THERAPY/MEDICATIONS FOR THIS PROBLEM? IF SO, PLEASE LIST?

_______________________________________________________________________________________________

_______________________________________________________________________________________________

5. DID
ANY OF THESE TREATMENTS HELP? IF SO, PLEASE LIST:________________________________________

______________________________________________________________________________________________

6.
OTHER HEALTH CONDITIONS/MEDICATIONS?______________________________________________________