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:
PHONE:
(H)___________________________
(W)_________________________ (C)__________________________
DRIVER
LICENSE #
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?______________________________________________________