New Client Form

Your Name*

First Last

Spouse/Partner/Other Authorized Caregiver

Please provide us with the name(s) of any other human caregiver(s) that you authorize to make medical decisions for your pet.

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alternate Phone

Email*

Alternate Email

Preferred Method of Contact*

Email
Phone Call

Please let us know your preferred method for non-urgent messages and appointment confirmations from Eyeshine.

Pet Name*

Species*

Dog
Cat
Horse
Other

Breed*

Color*

Sex*

Pet Age (yrs)*

Primary Care Veterinarian

First Last

Please provide us the name of your pet's primary care DVM or the name of the hospital or clinic below if you do not see a specific DVM.

Name of Primary Care Veterinary Clinic*

Reason for Your Pet's Visit to Eyeshine

Please describe the reason you are bringing your pet to see us at Eyeshine Veterinary.

Your Pet's Medical Conditions*

Please list all known medical conditions or disorders that your pet has been diagnosed with by any DVM.

Your Pet's Medications*

Please include all medications that your pet takes by mouth or uses on the eye.

How did you hear about Eyeshine Veterinary?

We would really appreciate knowing how your heard about Eyeshine Veterinary. We're glad you're here!

Media Consent

Yes - I agree to Eyeshine Veterinary's social media policy
No - I prefer not to allow media consent

Image and Media Consent: Checking the box below confirms your acceptance of Eyeshine Veterinary’s image and media policy. This policy allows Eyeshine Veterinary and its agents to take photographs or likenesses of your pet, which may be posted on Eyeshine Veterinary’s website and/or social media and may also be used for such purposes as publicity, continuing education, advertising, publication, etc. If you do not wish for your pet’s photograph to be taken and possibly used in the manner described above, please leave the following box blank. You may rescind your approval in writing at any time and no new uses of your pet’s image will be created.

Signature*

STATEMENT OF OWNERSHIP AND CONSENT: My name typed here confirms that I am the owner and/or agent of the above animal and have the authority to consent to diagnostic and therapeutic procedures for this pet provided by Eyeshine Veterinary. I understand I will be provided with a verbal and/or written estimate for any procedures, diagnostic tests, or treatments recommended during my pet’s examination. I authorize Eyeshine Veterinary to communicate with and provide medical records to the primary care DVM listed above pertaining to my pet’s healthcare. I understand that Eyeshine Veterinary does not bill for services and that all fees are to be paid in full at the time service is rendered.

Date*

Thank you for allowing Eyeshine Veterinary to be part of your pet's healthcare team!

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Name

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(888) EYE-VET-5