5175 Pacific St. #A Rocklin, CA 95677-2753
(916) 624-4364
After Hours ER line : 916-960-6776
aecrocklin@gmail.com
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(916) 624-4364
aecrocklin@gmail.com
After Hours ER line : 916-960-6776
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Chico, CA
Placerville, CA
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New Client Form
Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.
Name
(Required)
First
Last
Spouse's Name
Preferred Phone Number
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Who else is authorized to make decisions about your pet's healthcare?
Phone
Do you give Animal Eye Center permission to take photos of your pet and use these images for the purposes of medical records, continuing education, teaching, and to use medical data from your pet's medical record for future scientific publications.
(Required)
Yes, I give permission
No
Pet's Name
(Required)
Species
(Required)
Dog
Cat
Bird
Rabbit
Reptile
Other
Breed
(Required)
Color
(Required)
Sex
(Required)
Male
Neutered Male
Female
Spayed Female
Age/Date of Birth
(Required)
Weight
Pet's Medical History (check all health conditions that apply)
Seizures
Thyroid
Diabetes
Skin Problems
Liver
Kidney
Allergies
Heart Condition
Other
If other
Please list all the medications your pet is currently taking and how often
Do you have a second pet?
(Required)
Yes
No
Pet's Name
(Required)
Species
(Required)
Dog
Cat
Bird
Rabbit
Reptile
Other
Breed
(Required)
Color
(Required)
Sex
(Required)
Male
Neutered Male
Female
Spayed Female
Age/Date of Birth
(Required)
Weight
Pet's Medical History (check all health conditions that apply)
Seizures
Thyroid
Diabetes
Skin Problems
Liver
Kidney
Allergies
Heart Condition
Other
If other
Please list all the medications your pet is currently taking and how often
Do you have a third pet?
(Required)
Yes
No
Pet's Name
(Required)
Species
(Required)
Dog
Cat
Bird
Rabbit
Reptile
Other
Breed
(Required)
Color
(Required)
Sex
(Required)
Male
Neutered Male
Female
Spayed Female
Age/Date of Birth
(Required)
Weight
Pet's Medical History (check all health conditions that apply)
Seizures
Thyroid
Diabetes
Skin Problems
Liver
Kidney
Allergies
Heart Condition
Other
If other
Please list all the medications your pet is currently taking and how often
Name of Referring Veterinarian
Name of Veterinary Hospital
Regular Veterinarian's Name
Name of Hospital
Describe Your Pet's Problem
Authorization for transfer of my pet's medical record
I authorize communication between Animal Eye Center and my referring veterinarian to obtain medical records
I do not authorize communication between Animal Eye Center and my referring veterinarian
Preferred Appointment Reminder Method
(Required)
Please select an option
Text
Phone Call
Email
Payment in full is required upon discharge of your pet.
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