New Client Form

Name*

First Last

Spouse/Partner

First Last

Phone (primary)

Phone (secondary)

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Email (primary)*

Email Address (secondary)

Who is your primary care veterinarian?*

What primary veterinary hospital does your pet attend?*

Pet's Name*

Breed*

Species*

Pet's Date of Birth*

Sex*

Female Intact
Female Spayed
Male Intact
Male Neutered

Which Eye(s) Involved?*

Right
Left
Both

Please describe your pet's eye complaint.*

How Long Have Symptoms Been Present?*

Duration of the problem? Please specify in days/weeks/months and/or years.

Symptoms*

Vision Loss
Vision Reduced
Squinting
Discharge
Cloudiness
Redness
Color Change
Other/None of the Above

Current Eye Medication(s)*

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

Current Diet*

Please describe including brand, product, amount given and frequency. Is it grain-free? Thank you.

Known Drug Allergies

Known Food Allergies/Sensitivities

Can they have treats during their visit?

Other Health Conditions/Medications*

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

Does your pet require a muzzle for evaluation of the eyes?*

Yes
Maybe
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?*

Fear Aggression
Territorial Aggression
Predatory Aggression
Intra-Household Aggression
Control Aggression
Resource Guarding/Possession Aggression
Leash Aggression
Other/None of the Above

Client Conduct Policy*

By clicking here you have read and agree to Animal Vision Center's client conduct policy

As a client of the Animal Vision Center, you are responsible for complying with our Client Code of Conduct

Client Code of Conduct

The Animal Vision Center seeks to continually provide a welcoming and safe environment for all of our clients and patients. As such, there are behaviors which will not be tolerated:

• Verbal abuse, malicious or harmful statements about others, or profanity
• Any form of harassment
• Making threats or using intimidating tactics
• Allowing your pet to threaten or intimidate another person(s) or patient(s)
• Public disclosure of another’s private information
• Suspicion of being under the influence of alcohol or behavior altering drugs
• Failure to comply with requests by our staff, including leashing/restraining your pet, wearing a face mask, etc.

In the event that your behavior does not comply with our client conduct policy, we reserve the right to discontinue providing services immediately. For the safety and well-being of our staff, clients, and patients, our conduct policy is strictly enforced. Non-compliance with our policy may result in corrective action being taken, which may include being asked to leave the property and the possible involvement of law-enforcement. We truly appreciate your cooperation and understanding and look forward to serving you.

Terms of Service*

By clicking here you have read and agree to Animal Vision Center's cancellation policy and terms

As your appointment time is reserved specifically for you, Animal Vision Center, LLC has a cancellation/no-show policy. Out of consideration for our patients, staff, and our doctors, we ask that you notify us 24 business hours in advance should you need to cancel or reschedule your appointment. Our business hours are Monday through Friday, 8:30am to 5pm. Messages left on Fridays or on weekends for Monday appointments do not qualify as advance notice because we do not retrieve those messages until Monday morning.

A “no-show” is when a client misses a scheduled appointment without cancelling it or providing 24 business hours notice of cancellation. In order to reschedule a missed appointment, you will be charged a missed appointment fee and be required to leave a NON-REFUNDABLE RETAINER equal to the amount of the initial consultation ($515) will be required ($235 for missed recheck appointments). This retainer amount will be credited toward the next appointment if that appointment is kept.

We do understand that unanticipated events happen occasionally; emergency cancellations are handled on an individual basis. As a courtesy, Animal Vision Center, LLC has email and voice reminder capability to help remind you about your appointment date and time; however, it does remain the client’s ultimate responsibility to keep track of scheduled appointments. We thank you in advance for abiding by these policies and helping us keep our patients, clients, and staff on schedule and safe!

Authorization*

I agree.

I authorize and direct the veterinarians at the Animal Vision Center to diagnose, prescribe, perform minor therapeutic procedures, that their judgement may dictate to be advisable for the patient’s well-being. No warranty or guarantee has been made as to the result or cure.

ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF VISIT.

In the event any balance due hereunder is not paid as agreed, the undersigned jointly and severally agree to pay all cost included in said unpaid balance, including a reasonable collection and/or attorney’s fees.

Todays Date*

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New Client & Pet Registration Form