Pet And Owner Information

Patient Name *

Breed *

Species *

Color *

Sex *

Male
Female

Is your pet Neutered/Spayed? *

Yes
No

Approximate Weight *

Date of Birth (Or Age of Patient) *

Owner’s Name *

First

Last

Spouse/Other Contact *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Place of Employment *

May we feature your pet on our social media? *

Yes
No

Contact Information

Phone *

Secondary Phone

Spouse/Other Contact Primary Phone

Spouse/Other Contact Secondary

Email Information

We will email you all of your medical records and receipt the day of your appointment. Please provide us with the best email address to send your information to: *

We will also email you to remind you of upcoming appointments.

If you prefer not to receive appointment confirmations via email please check here

Veterinarian Information

Referring Veterinarian

Hospital Name

Medical Information

Problem with eye *

Location *

Right
Left
Both

Duration of signs *

Is your pet on any eye medications: *

Yes
No

Has your pet/patient had any problems/reactions with ANY Medications?

Yes
No

Has your pet been diagnosed with diabetes? *

Yes
No

Does your pet have heart problems? *

Anesthesia problems? *

Does your pet have any major health problems? If so please explain

Is your pet/patient taking any other medications NOT related to the eye? *

Has Your Pet Ever Needed A Muzzle During An Exam?

Yes
No

Payment can be made by cash, check, Care Credit, and any major credit card. There is a $40.00 fee for all returned checks. Any delinquent account requiring legal action may be subject to a 33 1/3% attorney’s fee in addition to all court costs. All appointments (including new,rechecks and post operative) will have an exam fee.

PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED.

Signature *

Clear Signature

Date *

Richmond Office Hours:

Monday through Thursday 8:30am - 4:30pm

Friday 8:30am - 3:30pm

Charlottesville Office Hours vary, please call for hours.

Doctor’s hours vary from our office hours

AAnimal Eye Care of Richmond is not a boarding facility, therefore all pets left for procedures/surgeries must be picked up by the close of business the day of the procedure.
Follow up appointments and postoperative rechecks WILL have an examination charge +/- any diagnostic charges that are performed, unless the doctor tells you otherwise.
Payment is due at the time of service. Unfortunately, we do not bill for services or medications.
If your pet is not picked up by the close of business, we will transport your pet to the Veterinary Referral and Critical Care Center in Manakin Sabot and you will incur a travel charge from us AND additional boarding fees, etc from the emergency center.

Signature *

Clear Signature

Date *

New Patient Form

New Patient Form

Pet And Owner Information

Contact Information

Email Information

Veterinarian Information

Medical Information

Richmond Office Hours:

Monday through Thursday 8:30am - 4:30pm

Friday 8:30am - 3:30pm

Charlottesville Office Hours vary, please call for hours.

Doctor’s hours vary from our office hours

We’re here for you and your pet.

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Locations

Contact Information

Hours