Ophthalmology Intake Form

Client Name *

Today's Date

Email *

Phone

Pet Name

Pet Age

Issue

How long have these changes been present?

Does your pet have any other health issues?

Allergies
Hormonal Disease (e.g. Cushings or Thyroid)
Diabetes
High Blood Pressure
Heart Disease
Kidney or Urinary Tract Disease
Liver or Pancreatic Disease
Respiratory Disease
Nervous System Disease (e.g. seizures)
Gastrointestinal Disease

Is your pet currently taking any non-eye medications?

If yes, please explain

Is your pet currently taking an anti-inflammatory medication (e.g. Rimadyl/Carprofen/Metacam/Galliprant)

Is your pet currently taking an allergy medication?

Is your pet currently taking any pain medication (e.g. Gabapentin, Tramadol)

Has your pet recently traveled outside of Oregon?

Has your pet had any lab work performed recently?

If yes, please indicate when and where this was performed.

Has your pet had any other diagnostic tests performed? (e.g. x-ray, CT or MRI scan)

If Yes, please indicate when/where.

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Our team members will be working very close to your pet’s face during the examination. This can be scary or intimidating for some pets. Please, for safety reasons, notify us if you believe your pet may require a muzzle prior to the examination.

Does your pet need a muzzle?

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If you are a human seeing this field, please leave it empty.

Have a Question?

We’re here to help, info@vrcvet.com or call 541-209-6960.

Ophthalmology Intake Form

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