New Client Form

5175 Pacific St. #A Rocklin, CA 95677-2753
(916) 624-4364
Emergency Line (After Hours Only) : 916-960-6776
aecrocklin@gmail.com

(916) 624-4364
aecrocklin@gmail.com

Emergency Line (After Hours Only)

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Ask us about our new Grass Valley location!

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 City State / Province / Region ZIP / Postal Code Country

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)

Payment in full is required upon discharge of your pet.

I understand and accept that charges for the new patient exam and up to three routine diagnostic tests could go up to $350. Medications and any procedures recommended are additional and estimates are provided upon request.(Required)

I have read and understand.

I understand and accept as a new client emergency exam that charges for the initial exam fees could go up to $500. Medication’s and any procedures recommended are additional and estimates are provided upon request.(Required)

I have read and understand.

I understand my $178 deposit is nonrefundable if I cancel within 48 hours of my initial appointment.(Required)

I have read and understand.

By signing this form, I acknowledge that I have read, understood, and agree to these policies.(Required)

Your Name
Your Name
Your Name

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Schedule An Appointment

Your pet’s eye health is crucial. Let us know if there is something you’re concerned about. Request an appointment by calling (916) 624-4364. We look forward to seeing you and your pet!

Have Questions?

Get in touch! Complete the form, and a member of our team will be in touch with you shortly.



Address

5175 Pacific St. #A
Rocklin, CA 95677

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Contact Information

Phone: 916-624-4364
Fax: 916-632-9138
Email: aecrocklin@gmail.com



Hours

Monday-Friday: 9 AM – 5 PM
Saturday & Sunday: Emergency Appointments

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We proudly serve the pets of Rocklin, CA and the surrounding areas:

Roseville, Folsom, Lincoln, El Dorado Hills, Sacramento,
Auburn, Loomis, Davis, Elk Grove, Woodland, Yuba City, Marysville, Chico, CA