804-355-5594 aecrichmond@gmail.com

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Online Forms

New Patient Form

Save time at your next appointment! Please complete your required Form online from any device at any time before your visit.

New Patient Form

Please complete this form as completely and accurately as possible. If this is an emergency or your pet requires immediate attention, please call us at 804-355-5594 for a faster response.

- Step 1 of 3

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

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Other Contact *

Phone

May we feature your pet on our social media? *

Yes
No

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

If yes, please list them *

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

Yes
No

If yes, please list them *

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

How did you hear about us?

Primary Veterinarian
Friend
Google Search
Tik Tok
Facebook
Instagram
Other

If other, where did you hear about us?

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 and rechecks) will have an exam fee. PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED.

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

Animal 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 each visit 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 *

Date *

Name

We’re here for you and your pet.

We proudly serve the pets of central VA, and beyond. We look forward to seeing you and your pet! You can request an appointment by clicking the button below.

Have A Question?

Please complete the form below, and a member of our team will get back to you as quickly as possible.

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Locations

Midlothian:
2861 Huguenot Springs Road Midlothian, VA 23113

Charlottesville:
370 Greenbriar Drive Suite B
Charlottesville, Virginia 22901
(located inside the Virginia Veterinary Specialists)

Fredericksburg:
Visit us in our mobile unit located in the parking lot of White Oak Animal Hospital
10 Walsh Lane
Fredericksburg, Virgnina 22405

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Contact Information

All Locations: 804.355.5594
Fax: 804-794-1884
Email: aecrichmond@gmail.com

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Hours

Midlothian Hours:
Mon-Thu: 8:30 am – 4:30 pm
Fri: 8:30 am – 3:30 pm
Sat-Sun: Closed

Charlottesville Hours:
9:30 am-2:30 pm on selected Thursdays

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