New Patient Form vision. passion. purpose. Please fill out the information below! We can’t wait to meet you and your best friend! About YouYour Name:* First Last Your Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What is the best place to reach you by phone?* Work Home Cell Other Best Phone Number:*Seconary Phone Number:Partner/Spouse Name (if applicable): First Last Partner/Spouse Phone Number (if applicable):Your Email (for discharges and receipts only):* Family VeterinarianYour Family Veterinarian/Name of Clinic (They’ll get updates about your visits): Were you referred to us by a veterinarian? Yes No If so, which one?Tell us who referred you. About Your Best FriendYour Pet’s Name:* First Breed:* Age:* Male or Female:* Male Female Neutered or spayed?:* Yes No Weight:* What is the general problem?*(e.g. my dog/cat’s right eye has been squinting, my dog/cat’s left eye has been red, there is a lot of discharge coming from both eyes, etc.)Eye/s affected:* Left Right Both How long has this problem been going on?*Has your pet experienced any eye problems prior to this one? Yes No Is the condition getting worse, better or staying the same? Worse Better Same What previous medications has your pet been prescribed for the eyes? (Please bring all medications with you to your appointment)*List medication and frequency of administrationHave any previous medications helped the issue? Yes No Does your pet have eye discharge?* Yes No If yes, check all that apply. Watery Mucoid (aka goopy) Mucopurulent (aka yellow-green and pus-like) Is your pet experiencing any of these symptoms, check all that apply:* Redness Squinting Eye cloudiness Swelling or displacement of the eye/s Poor vision (e.g. running into objects, inability to find treats on the floor, difficulty with stairs, etc.) No Is your pet on any of the following medications?(check all that apply) Please note, flea and heartworm medications and over the counter supplements will not affect our diagnosis or treatment (aka you do not need to include these). Cushing’s medications (e.g. trilostane, mitotane) Heart medications (e.g. benazepril, furosemide [Lasix], pimobendan [Vetmedin]) Medicated arthritis medication (e.g. carprofen, Galliprant, meloxicam, Rimadyl) Prednisone or other oral steroids (pills given by mouth) Thyroid medication (e.g. levothyroxine [Soloxine]) None (other than over the counter supplements and flea/heartworm prevention) Is your pet a diabetic?* Yes No Have you been told by a veterinarian that your pet has a heart murmur?* Yes No How would you rate your pet’s overall health?* Excellent, no other issues other than +/- the eye problem Very good, a few problems here and there, but overall, doing very well +/- the eye problem Good, struggles with a few chronic (long-term) health issues, but has a good quality of life currently +/- the eye problem Somewhat poor, multiple health issues, we are dealing with several other problems +/- the eye problem Poor, I am concerned about my pet’s overall quality of life and we are struggling with many health issues +/- the eye problem Social Media - Follow us on Facebook, Instagram and Twitter!Allow social media sharing?*Animal Eye Clinic would love to share your pet’s picture/name on social media, especially since they are the cutest pet out there! ** Please note - we will never use pet parent names ** Follow us on Facebook, Instagram (@indyanimaleyeclinic) and Twitter (@indyaec)! Yes, please share. No, thank you. SignatureSign here please! We can’t wait to see you!!*Please type your name. Notice of Cancellation*A $30 fee will be assessed if you fail to provide notice of cancellation 24 hours prior to your appointment. I understand and accept AEC's 24 hour cancellation policy. CAPTCHA