Eye Appointment Form

What is your pet's name?*:

What is your name?*:

Phone number*:

Email Address*:

Please describe the first time symptoms started :

Which eye(s) is affected?*:

Right eye
Left eye
Both eyes

If there is discharge, what colour is it?:

Is there redness?*:

Yes
No

Is your pet squinting?*:

Yes
No

Is your pet pawing at his/her face?*:

Yes
No

Is there any apparent swelling around the eye or other areas of the face?*:

Yes
No

Is your pet tilting their head?*:

Yes
No

Have you seen any incidents that may have caused trauma to your pet's eye(s)?*:

Have you started your pet on any medications? If so, what medications and what dosage?*:

Please rate your pet's itchiness*:

Score from 1-10, 1 being not itchy at all, 10 being extremely itchy

Have you noticed any changes in your pet's personality or behaviours?*:

Yes
No

Is your pet on flea/tick/heartworm prevention currently?*:

Yes
No

When was the last dose of flea/tick and or heartworm prevention given?*:

What diet is your pet currently eating?*:

Please note canned and dry food

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