What is your scheduled or preferred appointment location?* Lafayette Fremont San Rafael - PESCM No Preference / First Available Owner's Name First Last Pet's Name* Email* Date* MM slash DD slash YYYY Please 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? Right Left Both Please choose the best description of your pet's vision: Excellent vision Moderate vision Poor or Partial vision Complete blindness Poor night vision Poor day vision How long has this problem been going on? Any discharge (Check all that apply): Yellow Green White Grey Clear Brown Is it worse, better, or the same? Worse Better The same Please 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? Increased Decreased Same Has your pet currently been or previously had: Coughing Sneezing Vomiting Diarrhea Has your pet been drinking or urinating more than usual? Yes No Does your pet have any history of seizures? Yes No If 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? Yes No Any 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? Yes No What is your pet's diet?Has your pet had any recent blood work in the last three months?