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)

Primary Owner

Name(Required)
Address

Secondary Owner or Emergency Contact

Name
Address

Patient Information

Please complete the following for the pet we are seeing today.
Species
Gender

Referring Veterinarian

Primary Veterinarian (if different from above)

How did you hear about us?

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.

Date(Required)
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 History

Please 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.
2. Do you think your pet is experiencing any eye related pain?
3. Can your pet see?
4. Which eye has the current eye problem?
5. Approximately how long has the problem existed?
6. Has your pet had any eye problems prior to this current eye problem?
7. Does your pet have any change in overall color of one or both eyes?
8. Does your pet have any allergies?
Food Allergies
Environmental allergies
No known allergies
9. Does your pet have any of the following symptoms that may be consistent with allergic disease?
10. Does your pet sleep with eyelids:
11. Does your pet have any ocular discharge?
Color
Consistency
12. Does your pet violently shake his head when playing with toys?
15. Does your pet have any drug allergies or sensitivities that you are aware of?
Dental cleaning
17. When was the last time your pet had lab work performed?