Patient History Form:
For Pet Owners

Use this form to share your pet’s medical history with our team — including current symptoms, medications, allergies, and any prior eye care. The more we know going in, the more we can focus your appointment on what matters: your pet’s vision and comfort.

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Name*

First Name Last Name

Phone*

Email Address*

Pet’s Name*

When was the problem first noted?*

Which eye(s) is affected?*

Since first noting the problem, it has:*

Squinting / Holding the eye shut*

Pawing / rubbing at the eye*

Discharge / Excessive tearing*

Hazy / Cloudy Eye*

Change in vision*

Blindness*

My veterinarian diagnosed the problem (specify below)

Have you treated your pet's eye condition with any medications?*

Yes

If you have treated your pet with medications, please list the medications, dosing, and frequency of administration below:

Does your pet have any other health conditions?*

Yes

If your pet has other health conditions, list them below:

Who is your primary care veterinarian / veterinary practice?*

Has your pet been seen at any other vet’s office or speciality hospital within the last 12 months? If so, please list:

Our doctor(s) and nurses will be close to your pet’s face for the examination. For the safety of the Vet Vision staff, please let us know before your pet is examined if your pet:*

Is better without you present

Will require a muzzle for the exam

Will require pre-visit sedation medications*

None of the above

*If you do not have access to the necessary medications, please contact your veterinarian to ensure a quality examination and experience.

Consent & Policies*

You will be asked to complete a consent to examine and policy form when you arrive for the appointment. The following is a preview of the contents so that you may review them in advance.

Consent to Examine
I, the undersigned, am the owner or agent of the owner of the animal listed and have the authority to execute this document. I authorize the Vet Vision Center to perform a routine ophthalmic examination which may or may not include measurement of tear production (Schirmer Tear Test), intraocular pressure (Tonometry), and corneal staining for ulceration (Fluorescein Stain).

Financial Agreement
I agree to pay in full for services rendered. I understand the estimate for these services and that I am legally responsible for the full amount of the invoice the day that services are performed. In the event that my pet is admitted, a deposit totaling the amount of the low end of the estimate will be required. Vet Vision Center accepts payment in the form of cash, check, credit card, and CareCredit. In the event that a check is returned, you will be assessed a Returned-Check Fee of $25.

Appointment Arrival Policy
At Vet Vision Center, our team carefully plans each day around scheduled appointments to ensure we can provide timely, attentive care to every patient. We ask that you arrive 5 minutes before your pet’s scheduled appointment time to allow a few minutes for check-in.

If you’re going to be 5 minutes or more late for your appointment start time, please give us a call as soon as you know so that we may review the schedule and determine the best options and how to proceed. This helps us keep the schedule running smoothly while making sure we have enough time to provide the best care for your pet.

Cancellation and Missed Appointment Policy
We understand that life can be unpredictable, and unexpected situations may arise. If you need to cancel or reschedule your pet’s appointment, we kindly ask for at least 24 hours’ notice whenever possible. Providing advance notice allows us to offer the appointment time to another pet in need of care.

Appointments canceled with less than 24 hours’ notice may be subject to a cancellation fee. Missed appointments without notice (“no-shows”) may result in a fee or require a deposit before scheduling future appointments.

We recognize that emergencies, family crises, severe weather, transportation issues, and unexpected pet health concerns can occur. If you experience circumstances beyond your control, please contact us as soon as possible. We review these situations individually and may waive fees at our discretion.

Photographs & Social Media
We enjoy sharing photos and videos of our patients and their families on social media and occasionally on print materials and advertising outlets for the hospital. However, we will never do so without your consent! Please state whether you agree to grant the Vet Vision Center, its representatives, and employees the right to take photographs and/or videos of you and/or your pet, and to copyright, use, and publish the same in print and/or electronically.

Text Messaging
Please state whether you agree to grant if you consent to receive text messages from us. Message rates vary. Not all carriers are covered. Standard message and data rates apply. You may update your preference, and cancel your consent, by notifying us at any time or by replying STOP to any text message you receive from us.

Admission and Discharge
Inpatient Care Procedure
If your pet is scheduled for testing or a procedure you will be assigned a drop-off time. At admission, a member of our team will review the consent form, discuss medications, and answer any questions you may have. A deposit is required at that time, with any remaining balance due upon discharge. Please plan for approximately 30 minutes for the admission process. We will arrange a discharge time with you when the procedure or testing are complete.

No Overnight Care Notice
Vet Vision Center does not offer overnight hospitalization. All patients must be picked up by 5:30 PM on the day of their visit.

Late Pick Up Policy
I understand that if my pet is not picked up by 5:30 PM, an additional fee of $100 will be applied for each 15-minute interval thereafter. This fee helps cover the cost of staff remaining beyond regular hours to care for your pet.

We appreciate your understanding and cooperation in helping us maintain a safe and supportive environment for all patients and team members.

Discounts
Vet Vision Center is pleased to offer the following discounts
5% discount for seniors (65+) with a valid photo ID
5% discount for active-duty or retired military personnel, police officers, and firefighters
15% discount for nonprofit animal rescue organizations with current 501(c)(3) status

Please note that we are able to discount professional service line items on an invoice. We are unable to discount supplies, labwork, medications, or other retail items. We can apply discounts on current invoices. We cannot apply retro-active discounts.

If you qualify for one of these discounts, please let our team know at check-in so we can ensure it is applied to your account.

I have read the consent and policies.

Patient History Form: For Pet Owners

Patient History Form:
For Pet Owners