New Client Form

Welcome to Animal Vision Center

Thank you for giving us the opportunity to care for your pet. Completing this form helps ensure we have the most accurate and up-to-date information for your pet’s visit. Please fill it out as completely as possible so our team can request your pet’s medical history and provide the best possible care.

If you have NOT already scheduled an appointment, our team will contact you once we’ve received your pet’s medical records from your primary veterinary clinic.

New patient appointments scheduled based on current availability.

Owner Information

Primary Owner(Required)

First Last

Primary Phone(Required)

phone options

Cell
Landline

Consent

Check this box if you agree to receive texts/text reminders from Animal Vision Center LLC. Standard message and data rates may apply. You may opt out at any time by replying “STOP”. Animal Vision Center does not send spam or marketing text messages.

Primary Email Address(Required)

Secondary Owner

First Last

Relationship to Primary Owner?

Secondary Phone

Secondary Phone Options

Cell
Landline

Secondary Email Address

Mailing Address(Required)

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

Primary Veterinary Clinic

Please list the full name & location of the clinic your pet receives primary care from and the approximate date of your most recent visit.

Clinic Name:(Required)

Location(Required)

City State / Province / Region

Approximate Date of Last Visit

List the names of additional veterinary practices/clinics your pet has visited in the past year.

Please include the approximate date of your most recent visit for each clinic listed.

Are the Patient Records going to be under the primary owner’s name?(Required)

Yes
No

If No, what name will the records be under?

Pet Information

Pet's Name(Required)

Breed(Required)

Species(Required)

Canine
Feline
Avian
Other (please list)

Other

Pet's Date of Birth(Required)

Sex(Required)

Female Intact
Female Spayed
Male Intact
Male Neutered

Which Eye(s) Involved?(Required)

Right
Left
Both

Please describe your pet's eye complaint.(Required)

How Long Have Symptoms Been Present?(Required)

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

Symptoms(Required)

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

Current Eye Medication(s)(Required)

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

Diet

Diet(Required)

Please describe your pet’s diet - including brand, product, amount given and frequency.

Is this a grain-free diet?(Required)

Yes
No
Unsure

Can your pet have treats during their visit?(Required)

Yes
No

If your pet has specific food allergies, please list:(Required)

Chicken/Poultry
Beef
Other

Other, please list:

Other Health Conditions/Medications

Known Drug Allergies(Required)

Other Health Conditions/Medications(Required)

Has your pet seen an ophthalmologist in the past?(Required)

Yes
No

If Yes, please list their name(s) below.

Does your pet require the use of sedation/calming medications prior to veterinary visits?(Required)

Yes
No

If yes, please list the medication(s) & dose:

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

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

If your pet requires a muzzle, are you able to safely place the muzzle on your pet by yourself?(Required)

Yes
No

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

If Other, please list:

Appointment Information

Appointment Status(Required)

I already have an appointment scheduled with Animal Vision Center
I have not yet scheduled an appointment with Animal Vision Center

Have you visited Animal Vision Center with another pet in the past?(Required)

Yes
No

If Yes, please tell us your pet's name(s) so we can locate your account.

Client Conduct Policy(Required)

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(Required)

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 in addition to a late arrival 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.

We make every effort to be on time for all of our appointments. Unfortunately, when even one patient arrives late for their appointment, it can alter the entire schedule for the day. Therefore, a client that arrives 10 minutes or more late for their scheduled appointment will need to be rescheduled based on doctor discretion. If you feel you may be running late to your appointment for any reason, please reach out to us as soon as possible so we can plan effectively. Priority is given to patients that arrive on time.

A “no-show” or “missed appointment” is when a client misses a scheduled appointment without communicating the need for cancelation, arrives over 10 minutes late for an appointment or fails to provide 24 business hours (48 business hours for surgeries) notice of cancellation.

In order to reschedule a missed appointment, you will be charged a missed appointment fee up to $158 and be required to leave a NON-REFUNDABLE RETAINER equal to the amount of the consultation ($540 for initial consultation or $247-$354 for missed recheck/reevaluation appointments). This retainer amount will be credited toward the next appointment if that appointment is kept.

A veterinary/client relationship is built on mutual trust and respect. 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(Required)

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(Required)

New Client & Pet Registration Form