This form is designed to help our team gather important information about your pet's current status for your upcoming visit with our team!

What is your name? *

First

Last

Email *

Primary Phone *

What is your pet's name? *

Please describe the first time symptoms started: *

Which eye(s) is affected? *

If there is discharge, what colour is it?

Is there redness? *

Is your pet squinting? *

Is your pet pawing at his/her face? *

Is there any apparent swelling around the eye or other areas of the face? *

Is your pet tilting their head? *

Have you seen any incidents that may caused trauma to your pet's eye(s)? *

Have you started your pet on any medications? If so, what medications and what dosage? *

Please rate your pet's itchiness *

Score from 1-10, 1 being not itchy at all, 10 being extremely itchy

Have you noticed any changes in your pet's personality or behaviours? *

Is your pet on flea/tick/heartworm prevention currently? *

When was the last dose of flea/tick and or heartworm prevention given? *

What diet is your pet currently eating? *

Please note canned and dry food

Please upload pictures of any food, treats, medications or supplements your pet is currently taking:

Click or drag a file to this area to upload.

Did we forget something?

Please list any questions/problems/concerns that you would like addressed

Thank you for answering all of our questions, it helps us to deliver a more thorough and comprehensive experience for you and your pet!

Eye Appointment Form

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