If this is your animal's first time at one of our Northwest Animal Eye Specialists veterinary clinics, please complete our New Patient Form via any one of the following methods.

My Pet Needs an Appointment

We book all appointments based on urgency, so it is essential that you fill out this form in its entirety in order for us to help you and your pet. Once you submit your information, you must contact your veterinarian(s) immediately and have them send your pet's medical records to us. Once we receive your pet’s records, our staff will review those as well as the information you've submitted in this form and will get back to you via email or phone within 2-3 business days or less with options for scheduling an appointment. Even if your pet’s issue is urgent, please fill out this form and rest assured that we review this information as soon as it is submitted. We are currently booking out by roughly 1-2 months for non-urgent new patient appointments. If your pet has not seen a vet for this issue or if we do not receive records, your pet may be booked for our next available appointment. We recommend you use Google Chrome, Safari, or Mozilla Firefox to fill out this form. Please call us if you need assistance filling out this form.

New Patient Appointment – Pet Form *

I acknowledge that I have read, understood, and agreed to the above statement.

Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner

Primary Phone *

Email *

Preferred method of contact *

Cell Phone - Call

Cell Phone - Text

Address *

City *

State *

Zip Code *

Employer *

Occupation *

Which hospital do you prefer: *

Kirkland

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Are you a previous or current client? *

Yes

Please list the veterinarian (s) that your pet sees.

If your pet sees another specialist, please include them in the list

If you pet has seen more than one vet, which one referred you to NWAES?

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

Patient Information

Patient Name *

Birth Date / Age *

Breed *

Color *

Spayed/Neutered *

Yes

Gender *

What led you to believe that your pet has an eye problem? *

Loss of vision

Eye discharge

Change in color or cloudiness in the eye(s)

Problem detected by your veterinarian

Squinting

Other

How long has this problem been present? *

Which eye is affected? *

Right

Left

Both

Has the eye problem changed since you first became aware of it? *

Yes

If yes, how has it changed?

Have you treated the eye(s) with anything?

Yes

If so, please list all medications and how often used. Please explain which medication seemed to benefit your pet.

Your pet's vision seems to be: *

Excellent

Poor on occasion

Poor, especially in poor or dim lighting conditions

Poor, especially in bright lights

Poor, in regards to nearby objects

Poor, in regards to far objects

Completely absent

Has your pet had any other eye problems? *

Yes

If yes, what type?

Has your pet suffered from any other illness? *

Yes

If yes, what type?

Has your pet ever traveled outside of Western Washington? *

Yes

If yes, where?

Please list any additional information that you think we should know about you or your pet:

Consent for Treatment and Hospital Policies

WELCOME TO OUR PRACTICE

We are pleased to have the opportunity to work with you and your pet. We hope that this handout will provide you with information that will be helpful in making an informed decision regarding the services we can provide. It is very important for you to carefully read this agreement and any other handouts that we may provide you so we can discuss any questions you may have. We love working with animals and we strive to treat your pet, as we would want our pets treated. Our own pets are our children thus we can really relate to how much concern and anxiety you might be feeling about your pet’s eye problem. We have an extremely skilled and caring staff that will work with us to take care of you and your pet.

APPOINTMENTS

So that we may devote 100% of our time and energy to you, we do not “double book” appointments as some doctors do to circumvent problems with last-minute cancellations. Your appointment time is held exclusively for you. If you fail to show up for your appointment or cancel at the last minute, there is an open appointment slot when another pet could have been examined. There are many concerned pet owners just like you that are anxious to have their pet evaluated as soon as possible. If you will not be coming for your appointment, we ask that you give us at least 24 hours notice so that another client and pet may take your appointment time. You may be charged for the appointment without such notification.

PAYMENT POLICIES AND FEES

The fees you can expect to pay are as follows: New patient examination: $499.00. Recheck examination: $313.25. We require a 50% deposit before we proceed with emergency surgeries. *Price dependent upon how many staff members we need to call in in order to care for your pet. The fees allow for inclusion of the following tests that might be performed as part of the assessment: tear testing, intraocular pressure testing, and fluorescein staining. The examination fee does not include more advanced diagnostic testing, medications, or procedures. Emergency examinations may cost extra. Please ask BEFORE the examination if you have questions. There is only one occasion where recheck exams are at no charge and that is the first recheck exam after a surgery. ALL other recheck exams (after appointments or surgery) have an associated fee as indicated above.

Acceptable forms of payment include cash, check, American Express, debit, Discover, Visa, or MasterCard. We do not accept payment plans. For larger invoices, you have the option of applying for financing through Care Credit. It is a third party form of financing that does not have finance charges so long as you pay off the balance within 6 months. Insured Pets: You are still responsible for payment on your account at the time of service. Insurance reimbursement is between the insurance company and the insured. Overdue Accounts: Overdue accounts may be turned over to a collection agency, an attorney, and/or small claims court. You will be responsible for attorneys’ fees/costs or collection agency fees in the event your account becomes delinquent. Payments returned from your bank due to non-sufficient funds will be subject to a returned check fee of $64.50 for each item returned.

DAY HOSPITALIZATION

If your pet is left for a procedure, surgery, or examination, we ask that you return for your pet by the time the hospital closes at 5 PM, unless other arrangements have been made. If you have not returned by closing, your pet might be transferred to an emergency hospital for overnight hospitalization and treatments. Should this be necessary, you will be responsible for fees incurred at the emergency hospital.

EMERGENCIES AND HOW TO CONTACT US

We are usually in the hospital between 9 AM and 5 PM Monday through Thursday. However, we cannot take telephone calls if we are in surgery or in with a client. We have a very capable staff that is eager to help you. They can usually take care of your questions or concerns. If not, they will leave us a message and your call will be returned at our earliest availability. In the event of an after hours emergency, you should call the hospital for instructions on how to reach us. If we cannot be reached immediately and you feel that your pet has an urgent problem, you should call your regular veterinarian or an emergency hospital.

MEDICAL RECORDS

Your pet’s medical records are confidential. Information about your pet’s eye problems will not be released to third parties without your specific consent. There is one exception. We will fax a copy of the eye examination report to your regular/referring veterinarian unless you voice an objection to us. If for some reason you do not want your vet to see the examination report, please bring it to our attention before the examination. Keep in mind that we try to work as part of a health care team with your regular veterinarian.

INFORMED CONSENT

Your signature below indicates you have read the information in this document, that you understand it, and that you agree to abide by its terms during our professional relationship. If you have any questions, please feel free to discuss them with my staff prior to signing this agreement.

I hereby authorize Dr. Victoria Jones , and/or Dr. Dara Zirofsky to provide medical care for my pet(s): *

Date: *

Please print first and last name: *

Signature: *

Spam Blocker

New Patient Form

My Pet Needs an Appointment

Owner Information

Emergency Contact

Patient Information

Consent for Treatment and Hospital Policies

New Patients Welcome By Referral

IMPORTANT INFORMATION FOR OUR CLIENTS

We are closing our Renton Hospital and look forward to serving all new patients at our Kirkland location.