If you are human, leave this field blank.CLIENT HISTORY & INFORMATIONFirst Name *Last Name *DL #AddressApt, suite, etc.CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeMobile *HomeWorkEmailEmployerReferring VeterinarianAppointment Location *DallasGrapevineUnsurePet Name *Species *DogCatHorseOtherIf Other, SpecifyBreed *Sex *AgeColorNeuteredYesNoUnsurePlease complete all of the following questions to the best of your knowledge. Approximate dates are acceptable. Thank you for your help.Describe the complaintWhich eye(s) is (are) involved?LeftRightBothIf both are involved, which was first?LeftRightBothOnsetSuddenGradualWhen did you first notice the problem?If your pet has trouble seeing, describe the extentIf your pet’s vision is worse at a particular time of the day or night or in bright or dim lighting conditions, please describeIs the problem worse at certain times of the year than others?Is the problem painful or irritating to your pet?If you know of animals related to your pet which have similar problems, how are they related?Is your pet mostlyIndoorsOutdoorsPartly in and outDo you have small children in the household?YesNoDo you have other pets in the household?YesNoDo they have similar eye problems?YesNoDo they have other illnesses?YesNoDescribe the pet’s diet (type and amount)Have you noted any changes in the amount of water your pet drinks?IncreasedDecreasedNo changeDon’t knowIf so, please describe the degree of changeIf you notice any changes in urination, please describeDoes your pet have accidents in the house?YesNoWhat treatment(s) has your pet received, and how long has your pet been receiving the treatment(s)?Have the treatments helped? Please explainWhen did your pet last receive treatment and what was it?Does your pet have any other medical problems?Does your pet show any other abnormal signs?Explanation of Fees *Medical fees, in all fields of medicine, have been rising because of increased cost. The fees for services are usual and customary charges for the kind of specialized services rendered, and are comparable to those of other veterinary ophthalmologists across the United States. Fees are payable when services are rendered. Payment can be made in cash, check or by Visa, Mastercard, Discover, American Express, or Care Credit.I understand and agreeCaptcha *reCAPTCHA is required.Submit