Client and Patient Form

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Date

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 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:

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:

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!

Client and INITIAL PATIENT HISTORY FORM

Client/Owner Information:

Patient Information:

Referring Veterinarian Information:

Patient General History:

Patient Ophthalmic History:

Patient Medication History

Ocean Veterinary Ophthalmology, LLC Policies

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