Do you have an existing appointment? Yes No Do you have a preference in location?No preference / First availableSan RamonFremontSan RafaelPleasantonWhere 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? Yes No As best you can recall, what was the diagnosis?Do you or your household require childproof containers? Yes No Do you wish to receive text message appointment reminders? Yes No Payment Policy* I/we understand the payment policy of Animal Eye Care and agree to take full financial responsibility for the pet listed Animal Eye Care requires pre-paid deposit of $95 for 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 $365 missed new appointment exam fee.
