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| 780-570-9999
Submit a Referral
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Menu
Home
About
Meet Our Team
Careers
Contact
Departments
Cardiology
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
Orthopedic Foundation for Animals (OFA)
Veterinarians
Submit a Referral
Continued Education
Testimonials
EMERGENCY
| 780-570-9999
Submit a Referral
Ophthalmology Questionnaire
Ophthalmology Questionnaire
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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?
