Patient History Form: For Pet Owners

Phone

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.

If you have your pet’s medical files, please upload them below:

Drop files here or

Max. file size: 49 MB.

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 agree to grant 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.

Yes, we agree to have photographs taken of our pets

No, we do not consent

Text Messaging*

Message rates vary and 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.

Yes, I agree

No, I have opted out of text messaging