Client and Patient Form

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Date

MM slash DD slash YYYY

Client/Owner Information:

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Primary Contact Number*

Secondary Contact Number

Have any of your other pets been examined by Dr. Samuel or Dr. Mancuso in the past?

Patient Information:

Pet's Name*

Name

Species:*

Other:

Breed:

Color:

Sex:*

Spayed/Neutered?*

Date of Birth/Estimated Date of Birth:*

Date of Birth/Estimated Date of Birth:

MM slash DD slash YYYY

Vaccination status (including Rabies) up to date?

Has your pet ever required a muzzle or special precautions to be examined?

Can we give your pet treats?

Referring Veterinarian Information:

Primary Care Veterinary Clinic/Hospital:

Primary Care Veterinarian Phone Number:

Primary Care Veterinary Name:

Other veterinarian(s) involved in your pet’s care:

Patient General History:

Has your pet had recent (within the last 3 months) blood work or radiographs (x-rays)?

Has your pet ever been diagnosed with

Diabetes

Gastrointestinal Disease

Pancreatitis

Seizures

Heart/Lung Disease

Liver Disease

Hypothyroid

Allergies

Systemic Hypertension

Kidney Disease

Hyperthyroid

Healthy but Has Eye Issue

Please list, if any, other previous or present illness your pet has been diagnosed with.

0 of 500 max characters

Patient Ophthalmic History:

Which eye(s) is/are affected?

What led you to believe your pet has an eye problem?

Pawing at eyes

Eye ulcer (i.e. scratch)

Glaucoma

Red eye

Eyelid issue

Decreased vision

Change in color or cloudiness

Eye discharge

Change in color

Blind

Squinting (holding eye closed)

Cataract

Veterinarian noted issue

Other, explain

Please describe your pet’s eye problem(s), if not mentioned above.

How long has this problem been present?

Has your pet had any other eye problems in the past?

If YES, please describe

Patient Medication History

Is your pet being treated with any eye drop(s) or ointment(s) CURRENTLY?*

Current eye drops/ointments

Are you administering any of the following medications to your pet CURRENTLY?

Rimadyl (Carprofen)

Prednisone/Prednisolone

Pimobendan

Prozac (Fluoxetine)

Deramaxx (Deracoxib)

Insulin

Enalapril/Benazepril

Gabapentin

Metacam (Meloxicam)

Trilostane

Lasix (Furosemide)

Tramadol

Galliprant (Grapiprant)

Denamarin

Amlodipine

Please list ALL medications your pet is currently taking for ANY medical condition (including the eye) CURRENTLY not listed above.Please include prescription medications, supplements and over the counter medications. Please include name, strength, and frequency.(i.e. Rimadyl tablets 50 mg orally twice daily)

Has your pet ever had a reaction to a medication, sedation, or anesthesia in the past?

Please include name of medication(s) and a brief description of your pet’s reaction.

Is there any additional information you would like to us to know?

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**PLEASE BRING ALL YOUR PET’SCURRENT EYE MEDICATIONS (DROPS OR OINTMENTS) AND CURRENT ORAL MEDICATIONS TO EVERY OFFICE VISIT (i.e. APPOINTMENTS, SUGERIES, PROCEDURES, etc.).**

Ocean Veterinary Ophthalmology, LLC Policies

Please checkmark at the end of each policy. Your signature below indicates that you have read and agree to the policies listed. (Updated 1.15.21)

I authorize Ocean Veterinary Ophthalmology to take photographs and other documentations of my pet for educational and promotional purposes

I authorize Ocean Veterinary Ophthalmology to take photographs and other documentations of my pet for educational and promotional purposes. All images, documents, videos, and other media will be altered to omit names and other identifying marks as to maintain confidentiality. I hereby grant consent for use of these documents without compensation and release Ocean Veterinary Ophthalmology from any and all claims arising from the use of these documents.

Treatment Policy:*

Treatment Policy: By signing this form, the owner authorized the veterinary to examine, treat, and/or prescribe medications for the animal described above. During your pet's admission to the clinic, we may utilize medications that although well tested and routinely used, may be considered off-label for a particular species or compounded by a pharmacy for our use.

I agree to the treatment policy. *

Cancellation/Late Arrival Policy:*

Late Arrival/Cancellation Policy: Arriving late for an appointment negatively impacts other clients’ schedule and OVO’s ability to stay on schedule. Late arrivals may experience significant wait times or may be required to reschedule, as clients arriving on time will be seen first. Cancellations of any appointment or procedures must occur 48 hours prior to the appointment. All missed appointments and appointments not cancelled in a timely fashion will be considered no-show appointments. After one no show appointment or after any single surgery/procedure not cancelled 48 hours prior to the scheduled appointment, clients will be required to leave a non-refundable deposit in order to schedule their next appointment or procedure.

I agree to the late arrival/cancellation policy. *

Prescription Refill/Dispensed Medication Policy:*

Prescription Refill/Dispensed Medication Policy: Patients must be examined annually to legally authorize refill requests. Prescription refills will be authorized based on the veterinarian’s discretion. Prescriptions filled at our practice may be picked up Monday, Tuesday, Thursday, Friday from 7:30 am-3:30 pm excluding holidays. ALL prescriptions including those filled at our clinic and external prescriptions (called in or faxed to a pharmacy) require 24-48 clinic hours to be completed. We provide written prescriptions for your pet at no charge. Prescription refills that need to be called in or faxed to a pharmacy are subject to a $50 charge. Per federal and state laws, any medications that have left the premises cannot be redispensed. We are unable to accept returns or issue refunds on any medication that has been taken out of the clinic.

I agree to the prescription refill/dispensed medication policy. *

Pick-Up Policy*

Pick-Up Policy: Our office hours are 7:00 am-3:30 pm Monday, Tuesday, Thursday, and Friday. Ocean Veterinary Ophthalmology is not a boarding facility, therefore all patients left for procedures/surgeries or drop-off/emergency appointments must be picked up by the close of business the day of the procedure or appointment. On the day of your pet’s procedure or drop-off/emergency appointment, the doctor may arrange for your pet to be discharged after 3:30pm on a case-by-case basis. If your pet is not picked up by the close of business, we will transport your pet to the Emergency and Critical Care Department at The Life Centre in Leesburg, Virginia and additional fees may be incurred.

I agree to the pick-up policy. *

Payment Policy: **

Payment Policy: The owner assumes responsibility for all charges incurred in the care of the animal described above. Payment is due in full when the animal is discharged. A deposit may be required when scheduling an initial or recheck appointment. A minimal deposit of two-thirds of the estimated cost of any procedure/surgery may be required prior to treatment. OVO accepts payments by cash, check, Mastercard , Visa , Discover , American Express and Care Credit . Returned checks will be assessed a $30 NSF fee in addition to the original face value of the check. This fee is separate from any bank charges incurred.

I agree to the payment policy. *

Thank you for choosing Ocean Veterinary Ophthalmology for the care of your beloved pet!

Name

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Alternative:

WPA