Do you have an existing appointment?YesNoDo you have a preference in location?No preference / First availableLafayetteFremontSan RafaelWhere 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?YesNoDo 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.
