New Client Form and Ophthalmic History Do you have an existing appointment?YesNoDo you have a preference in location?No preference / First availableLafayetteFremontSan Rafael - PESCMWhere did you schedule your appointment?LafayetteFremontSan Rafael - PESCMI'm not sureName First Last Spouse/partnerWhat is the best phone number to reach you at during the exam to go over findings and instructions?*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home #Business #Cell/other #Owner Date of BirthRequired for controlled substance RxOwner faxEmail Spouse Business #Spouse Cell/otherSpouse/partner email Pet nameBreedColorSex Male Male/Neutered Female Female/Spayed Birthdate/AgeCurrent weight if known (lbs)Referral Information, if not referred, then who is your regular veterinarian:Your Vet #1Clinic nameYour Vet #2Clinic nameDid your primary care veterinarian provide your pet with a diagnosis?YesNoAs best you can recall, what was the diagnosis?Do you or your household require childproof containers?YesNoPlease describe your pet's eye problem (check all that apply):* Loss of vision (see below) White spot on the eye Black spot on the eye Vet mentioned problem Swelling of the eye Swelling around the eye Pain-squinting/rubbing Cloudiness Red eye None of the above Please describe your pet's eye problem(s):Which eye(s) are involved?RightLeftBothPlease choose the best description of your pet's vision:Excellent visionModerate visionPoor or Partial visionComplete blindnessPoor night visionPoor day visionHow long has this problem been going on?Any discharge (Check all that apply): Yellow Green White Grey Clear Is it worse, better, or the same?WorseBetterThe SamePlease list all eye medications that have been used and frequency used:Has your pet had any previous eye problems? Please describe:Is your pet on any other medications (not for the eye)? If yes, please list:Does your pet have any other illnesses? If yes, please describe:How is your pet’s appetite?IncreasedDecreasedThe SameHas your pet currently been or previously had: Coughing Sneezing Vomiting Has your pet been drinking or urinating more than usual?YesNoDoes your pet have any history of seizures?YesNoIf yes, last seizure date:Has your pet ever traveled outside of Northern California? If yes, where and when?Are there any other animals in the house? What species? How many?Is your pet current on vaccines?YesNoAny known exposure to toxins? (rodent poison, poisonous plants, antifreeze, etc.)Additional symptoms, issues or concernsAny prior surgery? If so, what type and when?If your pet is a cat, does he or she go outside or live inside only?What type of food does your pet eat? (Brand/Type of Meat)Is the food grain free?YesNoWhat is your pet's diet?Has your pet had any recent blood work in the last three months?Do you wish to receive text message appointment reminders?YesNoPayment Policy*I/we understand the payment policy of Animal Eye Care and agree to take full financial responsibility for the pet listedAnimal Eye Care requires pre-paid deposit of the initial exam at the time of scheduling. A 50% deposit will be required prior to treatment on emergency, surgical or in-patient services. The balance will be due, in full, at the time of discharge. If for any reason you are unable to keep an appointment, we do require a 24 hour cancellation notice to avoid being charged a fee of $65 for the missed service or $330 missed new appointment exam fee.