EMERGENCY
| 780-570-9999
Submit a Referral
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Menu
Home
About
Meet Our Team
Careers
Contact
Departments
Cardiology
Anesthesiology
Dentistry & Oral Surgery
Diagnostic Imaging
Emergency and Critical Care
Internal Medicine
Neurology
Ophthalmology
Surgery
Pet Owners
What To Expect
Referral Process
Pet Admission Forms
FAQ
Submit a Request for an OFA Exam
Veterinarians
Submit a Referral
Continued Education
Testimonials
EMERGENCY
| 780-570-9999
Submit a Referral
Ophthalmology Questionnaire
Ophthalmology Questionnaire
Step
1
of
2
50%
Client Information
Owner Name
*
First
Last
Primary Phone Number
*
Email Address
*
Do you have medical insurance for your pet?
*
Yes
No
What company is it with?
*
Patient Information
Pet Name
*
Date of Birth
*
MM slash DD slash YYYY
Breed
Gender
*
F
FS
M
MN
Is your dog a working-dog?
*
Yes
No
What type of work?
*
Please explain
Where did you obtain your pet?
*
Rescue
Breeder
Pet Shop
Other
Where did you obtain your pet?
*
Are your pet's vaccinations up to date?
*
Yes
No
Any other pets in the household?
*
Yes
No
Please list
*
Any travel history outside of Alberta?
*
Yes
No
Please list
*
Any concurrent medical conditions or problems?
*
Yes
No
Please list
*
Any coughing/sneezing/vomiting/diarrhea?
*
Yes
No
Please list
*
Any changes in appetite or water intake that you have noted?
*
Yes
No
Please list
*
Does your pet have any dietary restrictions?
*
Yes
No
Please list
*
Current medications (including supplements) including frequency
*
Any recent bloodwork or testing that has been performed?
*
Yes
No
What eye condition/concern is your pet experiencing?
*
Which eye is affected?
*
Right
Left
Both
Is there any discharge from either eye?
*
Yes
No
How would you describe your pet's vision?
*
Has your pet’s vision changed recently?
*
Yes
No
How has it changed?
*
Is your pet’s vision the same during the day as night?
*
Yes
No
How is it different?
*
Do you feel your pet is in discomfort/pain?
*
Yes
No
How severe would you rank the pain?
*
Has the eye condition progressed/worsened?
*
Yes
No
Is there anything else you would like us to know about your pet?
Name
This field is for validation purposes and should be left unchanged.
