New Clients

Name(Required)

First Last

Spouse/Partner

First Last

Phone (primary)

Phone (secondary)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email (primary)(Required)

Email (secondary)

Who is your primary care veterinarian?(Required)

Pet's Name(Required)

Species(Required)

Breed(Required)

Pet's Age(Required)

Please enter your pet's age using either the exact date of birth or a number in years or months.

Date of Birth

Years

Months

Pet's Date of Birth

Age (Years)(Required)

Please enter a number from 1 to 100.

Age (Months)(Required)

Please enter a number from 0 to 11.

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Pet's Date of Birth

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Pet's Date of Birth

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Age (Years)

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Age (Months)

Sex(Required)

Female Intact

Female Spayed

Male Intact

Male Neutered

Which Eye(s) Involved?(Required)

Right

Left

Both

Problems(Required)

Vision Loss

Reduced Vision

Squinting

Discharge

Cloudiness

Redness

Color Change

Other/None of the Above

Please describe your pet's eye complaint(Required)

Duration of the problem? Please specify in days/weeks/months and/or years(Required)

Current Eye Medication(s)(Required)

Please note medication name, frequency of administration, and the eye(s) being treated. Thank you.

Known Drug Allergies

Known Food Allergies/Sensitivities

Can they have treats during their visit?

Yes

Other Health Conditions/Medications(Required)

Has your pet seen an ophthalmologist in the past? If so please list their name(s).(Required)

Does your pet require a muzzle for evaluation of the eyes?(Required)

Yes

Not that I am aware of; this would be the first time a veterinarian would have to muzzle my pet

Does your pet display any of the following types of aggression?(Required)

Fear Aggression

Territorial Aggression

Predatory Aggression

Intra-Household Aggression

Control Aggression

Resource Guarding/Possession Aggression

Leash Aggression

Other/None of the Above

Electronic Signature(Required)

Your typed name is your electronic signature.

Today's Date(Required)

New Client & Pet Registration Form

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