Animal Eye Specialists - New Client Form

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

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: Payment is due at the time services are rendered. Accepted forms of payment include cash, AmEx, Visa, Mastercard, Discover, and debit cards. Please note, we do not accept checks. The initial exam fee includes a thorough ophthalmic evaluation and standard eye diagnostic tests. Any additional testing, procedures, or medications will result in additional costs. Emergency or work in appointments will incur additional applicable fees.

Payment Policy(Required)

I understand the payment policy.

Cancellation Policy: Animal Eye Specialists requires at least 24 business hours’ notice for all appointment cancellations or rescheduling. If you no-show, cancel same-day, or provide late notice, you will be rescheduled as a work-in appointment, and all applicable work-in fees will apply. If a rescheduling fee is collected, it is non-refundable and will be forfeit if you no-show or fail to give 24 business hours’ notice again. If you attend your rescheduled visit as planned, the fee will be applied toward your pet’s visit.

Cancellation Policy(Required)

I understand and agree to the cancellation policy.

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.

This field is hidden when viewing the form

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.