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Client and Patient Form

Today Date:

Client/Owner Information:

Name:
Address:
Email:
Primary Contact Number:
Secondary Contact Number:
Have any of your other pets been examined by Dr. Samuel in the past?

Patient Information:

Pet's Name:
Species:
Other:
Breed:
Color:
Sex:
Spayed/Neutered?
Date of Birth/Estimated Date of Birth:
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:
Please list, if any, other previous or present illness your pet has been diagnosed with.

Patient Ophthalmic History

Which eye(s) is/are affected?
What led you to believe your pet has an eye problem?
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?
Please list ALL medications your pet is currently taking for ANY medical condition (including the eye) CURRENTLY not listed above.
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?

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)

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

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Signed by Michelle Samuel
Signed On: January 13, 2022

Timestamp

Audit

September 17, 2020 2:00 am EDT

Client and Patient Form Uploaded by Michelle Samuel - signed-document@oceanveteyes.com IP 153.219.44.107