Client Info *

First Name

Last Name

Client Date of Birth (DOB), necessary to prescribe DEA controlled medications to your pet

MM

DD

YYYY

Spouse/Partner

First Name

Last Name

Phone (primary) *

(###)

###

####

Phone (secondary)

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday

MM

DD

YYYY

Which Eye(s) Involved? *

Right

Left

Symptoms *

check all that apply

Vision Loss

Vision Reduced

Squinting

Discharge

Cloudiness

Redness

Color Change

Other/None of the Above

Veterinarian

First Name

Last Name

Please list ADDITIONAL veterinarian who currently cares for your pet

First Name

Last Name

Friend or Family

First Name

Last Name

TERMS OF SERVICE *

As your appointment time is reserved specifically for you, Vision Care for Animals has a cancellation/no-show policy. Out of consideration for our patients , staff and our Doctor, we ask that you notify us 24 business hours in advance should you need to cancel or reschedule your appointment. Our business hours are Monday through Friday, 8am to 5pm. Messages left on Fridays or on weekends for Monday appointments do not qualify as advance notice because we do not retrieve those messages until Monday morning. Vision Care for Animals will charge $380 for new appointments and $187 fee for missed recheck appointments without 24 business hour advance notification (48 hours for scheduled surgery). We do understand that unanticipated events happen occasionally; emergency cancellations are handled on an individual basis. As a courtesy, Vision Care for Animals has text, email, and voice reminder capability to help remind you about your appointment date and time; however, it does remain the client’s ultimate responsibility to keep track of schedule appointments.

By clicking here you have read and agree to Vision Care For Animals' cancellation policy and terms