Ophthalmology Questionnaire

CLIENT INFORMATION

Full Name *

Primary Phone Number *

Email Address *

Do you have medical insurance for your pet? *

Yes
No

Pet Name *

Date of Birth *

Breed *

Gender *

Is your dog a working-dog? *

Yes
No

Where did you obtain your pet? *

Is your pet up to date on vaccinations? *

Yes
No

Do you have any other pets in the household? If yes, please list: *

Has your pet travelled outside of the province recently? If so, where and when? *

Any concurrent medical conditions or problems? *

Any coughing/sneezing/vomiting/diarrhea? If yes, please describe. *

Any changes in appetite or water intake that you have noted? If yes, please describe. *

Does your pet have any dietary restrictions? If yes, please describe. *

Current medications (including supplements) including frequency *

Any recent bloodwork or testing that has been performed? *

Yes
No

What eye condition/concern is your pet experiencing? *

How would you describe your pet's vision? *

Has your pet’s vision changed recently? *

Yes
No

Is your pet’s vision different during the day as night?*

Yes
No

Do you feel your pet is in discomfort/pain? *

Yes
No

Has the eye condition progressed/worsened? *

Yes
No

Is there anything else you would like us to know about your pet?

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *