Northwest Animal Eye Specialists

13020 NE 85th Street
Kirkland, WA 98033

(425)827-3966

www.northwestanimaleye.com

MY PET NEEDS AN APPOINTMENT

Please note: We book all appointments based on urgency, so it is essential that you fill out this form in its entirety in order for us to help you and your pet. Once you submit your information, YOU must contact your veterinarian(s) immediately and have them send records to us. Once we receive your pet’s records, our staff will start the triage process and we will get back to you within 24 hours with options for scheduling your pet. Even if your pet’s issue is urgent, please fill out this form and rest assured that we review this information as soon as it is submitted. Please also take note that we are currently experiencing an influx of new patients and thus are booked out by roughly 3 months for non-urgent appointments. If your pet has not seen a vet for this issue or if we do not receive records, your pet may be booked for our next available appointment.

Appointment Request Form


I acknowledge that I have read and understood the above statement (required)
Yes
No
Tell us about YOU
First Name (required)

Last Name (required)

Phone number (required)

E-Mail Address (required) :
Are you a previous or current client? (required)
Yes
No
Not Sure
Would you prefer our Renton or our Kirkland location? (required)
Kirkland
Renton
Either is fine
Are you willing to go to either location if your pet’s issue is deemed urgent? (required)
Yes
No
Tell us about YOUR PET
Name (required)

Breed (if exact breed unknown, give us your best guess) (required)

Age (required)

Sex (required)

Please provide the name of the veterinarian(s) and clinic(s) that have seen your pet. (required)

Tell us about YOUR PET'S SYMPTOMS
Affected eye(s) (required)

When did you first notice this issue (required)

Is your pet experiencing any of the following: (required)
Squinting
Pawing/Rubbing
Discharge
Cloudiness
Redness
Please comment on any of the above checked fields with more detail (required)

Are you noticing a change in your pet’s vision (i.e. bumping into walls, missing treats, etc.) since this issue started? (required)

Please list your pet’s other medical issues (required)

Please list any prescription medications that you are currently giving your pet as well as the dosage and frequency (required)

Please list any additional information that you think we should know about you or your pet


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