Client and INITIAL PATIENT HISTORY FORM Client and Patient Form Step 1 of 5 20% HiddenDate MM slash DD slash YYYY CLIENT INFORMATION:Name* First Last Address* Street Address Address Line 2 City State / Province *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred method of contactPreferred method of contact:Phone CallEmailText messageEmail* Primary Contact Number*Secondary Contact NumberWork Number:How did you become aware of our practice?How did you become aware of our practice?VeterinarianWebsiteReviewFriend or RelativeACVO WebsiteOtherOther Have any of your other pets been examined by Dr. Samuel in the past?Have any of your other pets been examined by Dr. Samuel in the past?NoYes PATIENT INFORMATION:Pet's Name* Name Species:*Species: *CanineFelineOtherOther: Breed: Color: Sex:Sex:MaleFemaleSpayed/Neutered?Spayed/Neutered?NoYesDate of Birth: MM slash DD slash YYYY or Estimated Age:Approximately how long have you had your pet?How did you acquire him/her? Vaccination history (including Rabies) Up to Date?Vaccination history (including Rabies) Up to Date?NoYesCan we give your pet treats?Can we give your pet treats?NoYes Veterinary Clinic/Hospital Details:Primary Care Veterinary Clinic/Hospital: Primary Care Veterinarian Phone Number:Primary Care Veterinary Name: Other veterinarian(s) involved in your pet’s care: INITIAL PATIENT HISTORY FORMWhat led you to believe your pet has an eye problem?What led you to believe your pet has an eye problem? Pawing at eyes Eye discharge Squinting (holding eye closed) Eye ulcer (i.e. scratch) Red eye Cataract Change in color or cloudiness Glaucoma Decreased vision Blind Eyelid problem Veterinarian noted problem Other, explain Other How long has this problem been present? Which eye(s) is/are affected?Which eye(s) is/are affected?RightLeftBothHas the character of the eye(s) changed since you first noticed it?Has the character of the eye(s) changed since you first noticed it?NoYesUnsureIf YES, is the severity of the condition currentlyIf YES, is the severity of the condition currentlyBetterWorseNo changeDo you think your pet sees well inDo you think your pet sees well in Familiar surroundings? Strange surroundings? Surroundings in dim/dark lighting? Unsure Familiar surroundings?Familiar surroundings?NoYesUnknownStrange surroundings?Strange surroundings?NoYesUnknownSurroundings in dim/dark lighting?Surroundings in dim/dark lighting?NoYesUnknownDo you feel your pet is in pain?Do you feel your pet is in pain?NoYesUnsureAre you currently treating your pet for his/her eye problem?Are you currently treating your pet for his/her eye problem?NoYesIf YES, please choose the followingIf YES, please choose the following Current eye drops/ointments Current oral medications Current eye drops/ointmentsCurrent oral medicationsHas your pet had any other eye problems in the past?Has your pet had any other eye problems in the past?NoYesUnknownIf YES, please describePlease list the names of previous eye medications or oral medications used for your pet’s previous eye condition(s) if any.Has your pet had previous or present illness NOT related to the eye?Has your pet had previous or present illness NOT related to the eye?NoYesUnknownIf YES, what type Has your pet ever been diagnosed withHas your pet ever been diagnosed with Diabetes Cardiovascular Disease (Heart Murmur, Arrythmia) Systemic Hypertension Gastrointestinal Disease Liver Disease Kidney Disease Hyperthyroid Hypothyroid Seizure Allergies Other Other Please list ALL medications your pet is currently taking if any medications NOT related to the eye?:Please including prescription and over the counter medications, and any supplements.Does your pet have any known allergies to ANY medications?Does your pet have any known allergies to ANY medications?NoYesUnknownIf YES, describeHas your pet ever had a reaction/poor response to sedation or anesthesia?Has your pet ever had a reaction/poor response to sedation or anesthesia?NoYesUnknownIf YES, was your pet’s poor reactionIf YES, was your pet’s poor reaction Sedation Anesthesia Both Unsure If YES, please specify if the type of drug, name of drug (if possible) and a brief description of your pet’s reaction. Has you pet had blood work or radiographs (x-rays) performed in the last 3 months?Has you pet had blood work or radiographs (x-rays) performed in the last 3 months?NoYesUnknownIf YES, please list diagnostics and date.Has your pet had previous surgeries?Has your pet had previous surgeries?NoYesUnknownIf YES, please list procedure(s). Has your animal traveled outside of Virginia?Has your animal traveled outside of Virginia?NoYesUnknownIf YES, where? Has your pet ever required a muzzle or special precautions (i.e. oral/injectable sedation) to be examined by a veterinarian?Has your pet ever required a muzzle or special precautions (i.e. oral/injectable sedation) to be examined by a veterinarian?NoYesUnknownWe understand that going to a veterinary office can be a very stressful event for your pet! If your pet is nervous, fearful, and/or protective of you when visiting the veterinarian or if your pet has ever needed to wear a muzzle, displayed aggressive behavior to veterinarians, staff, or other pets or required chemical restraint/sedation to be examined, please let us know both at the time we are scheduling your pet’s appointment and at the time of your pet’s appointment. We would never hold aggressive/nervous behavior against your pet. OVO is committed to helping your pet while minimizing his/her stress. Knowing that your pet may need some extra TLC is helpful information, so that we can schedule his/her appointment appropriately. Is there any additional information you would like to us to know?Today’s best contact phone number: Please review the following informationYour initials and signature at the bottom of this form indicate that you have read and agree to each of the policies listedI 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.*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.YesNoCancellation/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/Prescription Refill 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. We provide written prescriptions for your pet at no charge. 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. Prescription refills that need to be called in or faxed to a pharmacy are subject to a $15 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 policyTreatment Policy:*Treatment Policy *: By signing this form, the owner authorized the veterinarian to examine, treat, and/or prescribe medications for the animal described above. I agree to the treatment 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 of two-thirds of the total 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. Should this account default and is referred to an attorney for collection, the owner agrees to pay all collection costs, including attorney fees, up to 40% of the principal amount due and owing when turned over for collection. 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. *Are you planning on paying by check?*Are you planning on paying by check? *NoYesIf YES, please provide the following information:Driver’s License #: State: Date of Birth: MM slash DD slash YYYY Thank you for choosing Ocean Veterinary Ophthalmology for the care of your beloved pet!