Please fill out as much information as possible. If you are bringing pet for a rescue organization, please fill out their address in the rescue section. If you do not have an appointment, please call to schedule.
Owner Information*
First
(Required)
Last
(Required)
Phone
(Required)
Email
(Required)
Spouse/Partner Name
First
Last
Phone
Email
Address*
Street Address
(Required)
City
(Required)
State/Region
(Required)
Postal/Zip Code
(Required)
Rescue Organization (Only if bringing pet in for a rescue)
Rescue Name
Phone
Rescue Address
Street Address
City
State/Region
Postal/Zip Code
Veterinarian’s Information
Veterinarian's Name & Clinic Name
(Required)
If your vet clinic has more than one location, please tell us which location you go to (address or crossroads).
Pet's Information*
Pet Name
(Required)
Breed
(Required)
Age
(Required)
Color
(Required)
Sex
(Required)
Intact Male
Neutered Male
Intact Female
Spayed Female
Does your pet have any special handling requirements we should know about?
(Required)
Non-eye Related Health Issues
Payment Policy
(Required)
Payment is due at the time services are rendered. Forms of accepted payment include: Cash, AmEx, Visa, Mastercard, Discover, and Debit Cards. The initial exam fee of $220 includes a thorough exam and standard diagnostic tests. Any additional tests, medications, and/or emergency fees will result in extra costs.
I understand the payment policy.
Payment is due at the time services are rendered. Forms of accepted payment include: Cash, AmEx, Visa, Mastercard, Discover, and Debit Cards. The initial exam fee of $220 includes a thorough exam and standard diagnostic tests. Any additional tests, medications, and/or emergency fees will result in extra costs.
Cancellation Policy
(Required)
Cancellation Policy: Animal Eye Specialists requires at least 24 business hours notice on cancellations. I understand that if I last minute cancel or no show, a non-refundable rescheduling fee of $220 will be required in order to reschedule to the next available appointment. I understand and agree that this fee will be forfeit if I no show to the visit or if I fail to give 24 business hours notice on rescheduling. If I make it to the appointment as scheduled, the fee will be applied to my pet's visit.
I understand and agree to the cancellation policy.
Cancellation Policy: Animal Eye Specialists requires at least 24 business hours notice on cancellations. I understand that if I last minute cancel or no show, a non-refundable rescheduling fee of $220 will be required in order to reschedule to the next available appointment. I understand and agree that this fee will be forfeit if I no show to the visit or if I fail to give 24 business hours notice on rescheduling. If I make it to the appointment as scheduled, the fee will be applied to my pet's visit.
Social Media Policy
(Required)
I authorize Animal Eye Specialists, PLLC to use my pet's information and medical history for use on their website and other social media outlets including but not limited to: Facebook, Twitter, Instagram, and blogs. I understand that consent is strictly voluntary and my personal information will not be shared.
I agree.
I DO NOT agree.
I authorize Animal Eye Specialists, PLLC to use my pet's information and medical history for use on their website and other social media outlets including but not limited to: Facebook, Twitter, Instagram, and blogs. I understand that consent is strictly voluntary and my personal information will not be shared.
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Payment Policy
(Required)
I understand the payment policy.
This field is hidden when viewing the form
Cancellation Policy
(Required)
I understand and agree to the cancellation policy.
This field is hidden when viewing the form
Social Media Policy
(Required)
I agree.
I DO NOT agree.