Client Information Form

Thank you for considering North Houston Veterinary Ophthalmology for your pet’s ocular care!

We are honored that you’ve chosen us to assist with your pet’s eye health. Our team is dedicated to providing the highest level of care, ensuring that your beloved companion receives the attention and treatment they deserve. If you have any questions or need further information, please don’t hesitate to reach out. We look forward to partnering with you in your pet’s journey to better vision and health.

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Client Information 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.

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Owner Name: *

Spouse’s Name:

Address *

Address Line 1

City

State

Zip Code

Employer: *

Email *

Cell Phone:

We must be able to reach you. Please provide us with any number that will allow us to contact you or another responsible party. Thank you!

Work Phone:

Home Phone:

PATIENT INFORMATION

Type *

Name: *

Breed *

Color: *

Sex *

Male
Neutered Male
Female
Spayed Female

Age: *

Yrs *

Mths *

Primary Veterinary Doctor: *

Primary Veterinary Hospital: *

Please list any health problems & Reason for Visit:

Initial Consultation Fee

An initial consultation fee of $200 will be collected. This fee includes:

Baseline testing
Comprehensive eye examination

Please note that this fee does not cover medication or additional services your pet may need. If further procedures are required, we will provide an estimate before proceeding.

Name

Client Information Form

Thank you for considering North Houston Veterinary Ophthalmology for your pet’s ocular care!

Client Information Form

PATIENT INFORMATION

Initial Consultation Fee

Contact Info

Location

Hours

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