New Client Registration Welcome to Veterinary Eye Institute. We kindly ask that you provide the following information so that we may become better acquainted. Please select the VEI location you would like us to send the completed forms.Location(Required) Anaheim, CA Upland, CA Deerfield Beach, FL Ft. Lauderdale, FL Gainesville, FL Ocala, FL Orlando, FL Plano, TX Primary OwnerName(Required) First Last Suffix Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneMobile PhoneEmail Address Secondary Owner or Emergency ContactName First Last Suffix Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneMobile PhoneEmail Address Preferred Method of Communication Patient InformationPlease complete the following for the pet we are seeing today.Pet's Name Species Dog Cat Other (please specify below) Other species Gender Male Male/Neutered Female Female/Spayed Breed Color Date of Birth (if unknown, please estimate age) Does your pet express aggressive or fearful behavior that would require a muzzle or other special care to ease their anxiety?(Required) Yes No Referring VeterinarianName Hospital Primary Veterinarian (if different from above)Name Hospital How did you hear about us?Veterinarian Client Referral Internet Other All fees are required to be paid in full following the completion of your visit. VEI accepts Mastercard, Visa, Discover, American Express, Care Credit, and cash. We do not accept checks. Signature(Required) Reset signature Signature locked. Reset to sign again Date(Required) Month Day Year Emergency examinations will include an additional emergency fee. Please note, additional fees for diagnostics or treatment may be necessary and can vary by patients condition. A written estimate for any procedure done outside of our standard ophthalmic examination can be provided before any work is performed. Please feel free to ask with specific questions.Initial Eye Exam HistoryPlease answer the following questions to the best of your ability. You may not know the answer to all of the questions and that’s okay. This information will help us to have a better understanding or your pet’s condition. This questionnaire typically takes about 10-15 minutes to complete.1. What is the reason for your visit? What eye related problem(s) does your pet have that concerns you? My veterinarian first noticed the eye problem. The diagnosis was 2. Do you think your pet is experiencing any eye related pain? Yes No Not sure If yes, why do you feel this way? 3. Can your pet see? Yes No Not sure On a scale of 0-10, based on your pet’s behavior, how would you rate their vision? (0=absolutely NO vision, 10=excellent vision) 4. Which eye has the current eye problem? Right Left Both 5. Approximately how long has the problem existed?Hours Days Weeks Months Years 6. Has your pet had any eye problems prior to this current eye problem? Yes (please list the condition, the eye afected and any treatments that seemed to help) No List conditions 7. Does your pet have any change in overall color of one or both eyes? Red White/Cloudy Dark No change 8. Does your pet have any allergies?Food Allergies Food allergies (if known, please list). Food Allergies Environmental allergies Environmental allergies (if known, please list). Environmental Allergies No known allergies No known allergies 9. Does your pet have any of the following symptoms that may be consistent with allergic disease? 'Itchy' eyes as demonstrated by rubbing at the eyes or rubbing them on objects like carpet or furniture? A history of ear problems Licks or chews on paws 'Itchy' skin 10. Does your pet sleep with eyelids: Open Partially open Closed Not sure 11. Does your pet have any ocular discharge? None Color Clear White/Grey Yellow/Green Rust/Brown/Black Consistency Clear Fluid/Watery Thick/Mucous 12. Does your pet violently shake his head when playing with toys? Yes No 13. What other medical conditions does your pet have? 14. What medications (topical and oral) is your pet currently being given and what is the frequency of administration? (please include all supplements including fish oil, herbal supplements, arthritis medications, etc.) 15. Does your pet have any drug allergies or sensitivities that you are aware of? Yes No Partially open 16. When was the last time your pet had a dental cleaning? Dental cleaning Unknown None 17. When was the last time your pet had lab work performed?Approximate timeframe (ie. Last week, last month, etc.) If known, please list the labwork that was performed. 18. Additional comments:Release Authorization VEI/MedVet may use and disclose information from your pet’s medical record, including medical information, demographic information, and images for educational and learning purposes, scientific investigations, and research publications. Your pet’s information may be disclosed to veterinarians, veterinary technicians, students, research collaborators, and other personnel within and outside of VEI/MedVet. All personal identifying information will be removed prior to disclosure to individuals outside of VEI/MedVet and prior to presentation and/or publication. I authorize use of my pet's information for educational and research purposes.Initial I authorize use of my pet's first name, photograph and clinical information on Veterinary Eye Institute/MedVet’s website, social media, news media page or within informational pamphlets. Under no circumstances will my name, my personal or financial information be shared through these media sources.Initial
