(required) I acknowledge that I have read, understood, and agreed to the above statement.
Tell us about YOU
First Name: (required) Last Name: (required) Cell Phone Number: (required) Please note that we send appointment reminders via text. If you prefer to receive appointment reminders via email or are not able to text, please let our staff know and we will gladly accommodate you. Street Address: (required) City: (required) State: (required) Zip Code: (required) Email: (required) Spouse/significant other: Employer: Work Phone Number: Home Phone Number: Emergency Contact Name and Number: For future patient-related communication, which contact method do you prefer? (required) Text on cell Call on cell Call on home phone Email 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 Please list the veterinarian(s) that your pet sees. If your pet sees another specialist, please include them in the list. (required) How did you hear about us? If your pet has seen more than one vet, which one referred you to NWAES? (required)
Tell us about YOUR PET
Pet's Name: (required) Species: (required) Breed: (required) Age, Date of Birth (if known): (required) Sex: (required) Male Female Color: (required) Is your pet spayed or neutered? (required) Yes No What led you to believe that your pet has an eye problem? (required) Loss of vision Eye discharge Change in color or cloudiness in the eye(s) Problem detected by your veterinarian Squinting Other How long has this problem been present? (required) Which eye is affected? (required) Right Left Both Has the eye problem changed since you first became aware of it? (required) Yes No If yes, how has it changed? Have you treated the eye(s) with anything? (required) Yes No If so, please list all medications and how often used. Please explain which medication seemed to benefit your pet. Your pet's vision seems to be: (required) Excellent Poor on occasion Poor, especially in poor or dim lighting conditions Poor, especially in bright lights Poor, in regards to nearby objects Poor, in regards to far objects Completely absent If your pet is a cat, is it: Indoor only Indoor/Outdoor Outdoor only Do you have any other pets? (required) Yes No If yes, do they have eye problems? Yes No Has your pet had any other eye problems? (required) Yes No If yes, what type? Has your pet suffered from any other illness? (required) Yes No If yes, what type? Has your pet ever traveled outside of Western Washington? (required) Yes No If yes, where? Please list any additional information that you think we should know about you or your pet:
CONSENT FOR TREATMENT AND HOSPITAL POLICIES
So that we may devote 100% of our time and energy to you, we do not “double book” appointments as some doctors do to circumvent problems with last-minute cancellations. Your appointment time is held exclusively for you. If you fail to show up for your appointment or cancel at the last minute, there is an open appointment slot when another pet could have been examined. There are many concerned pet owners just like you that are anxious to have their pet evaluated as soon as possible. If you will not be coming for your appointment, we ask that you give us at least 24 hours notice so that another client and pet may take your appointment time. You may be charged for the appointment without such notification.
PAYMENT POLICIES AND FEES:
The fees you can expect to pay are as follows: New patient examination: $412 Recheck examination: $214 New Patient Urgent Care examination: $513 After Hour Emergency examination (for current clients only): $549-654* - *Price dependent upon how many staff members we need to call in in order to care for your pet. We require a 50% deposit before we proceed with emergency surgeries. The fees allow for inclusion of the following tests that might be performed as part of the assessment: tear testing, intraocular pressure testing, and fluorescein staining. The examination fee does not include more advanced diagnostic testing, medications, or procedures. Emergency examinations may cost extra. Please ask BEFORE the examination if you have questions. There is only one occasion where recheck exams are at no charge and that is the first recheck exam after a surgery. ALL other recheck exams (after appointments or surgery) have an associated fee as indicated above.
PAYMENTS FOR SERVICES PROVIDED FOR YOU AND YOUR PET IS EXPECTED AT THE TIME SERVICES ARE RENDERED:
Acceptable forms of payment include cash, check, American Express, debit, Discover, Visa, or MasterCard. We do not accept payment plans. For larger invoices, you have the option of applying for financing through Care Credit. It is a third party form of financing that does not have finance charges so long as you pay off the balance within 6 months. Insured Pets: You are still responsible for payment on your account at the time of service. Insurance reimbursement is between the insurance company and the insured. Overdue Accounts: Overdue accounts may be turned over to a collection agency, an attorney, and/or small claims court. You will be responsible for attorneys’ fees/costs or collection agency fees in the event your account becomes delinquent. Payments returned from your bank due to non-sufficient funds will be subject to a returned check fee of $40.00 for each item returned.
If your pet is left for a procedure, surgery, or examination, we ask that you return for your pet by the time the hospital closes at 5 PM, unless other arrangements have been made. If you have not returned by closing, your pet might be transferred to an emergency hospital for overnight hospitalization and treatments. Should this be necessary, you will be responsible for fees incurred at the emergency hospital.
EMERGENCIES AND HOW TO CONTACT US:
We are usually in the hospital between 9 AM and 5 PM Monday through Friday and 9AM to 4PM on some, but not all, Saturdays. However, we cannot take telephone calls if we are in surgery or in with a client. We have a very capable staff that is eager to help you. They can usually take care of your questions or concerns. If not, they will leave us a message and your call will be returned at our earliest availability. In the event of an after hours emergency, you should call the hospital for instructions on how to reach us. If we cannot be reached immediately and you feel that your pet has an urgent problem, you should call your regular veterinarian or an emergency hospital.
Your pet’s medical records are confidential. Information about your pet’s eye problems will not be released to third parties without your specific consent. There is one exception: We will fax a copy of the eye examination report to your regular/referring veterinarian unless you voice an objection. If for some reason you do not want your vet to see the examination report, please bring it to our attention before the examination. Keep in mind that we try to work as part of a health care team with your regular veterinarian.
By providing your name below and authorizing our staff to provide care for your pet, you indicate that you have read the information provided regarding our consent for treatment and hospital policies. By providing your name below you also indicate that you that you understand the policies above and that you agree to abide by its terms during our professional relationship. (required) I hereby authorize Dr. Victoria Jones, Dr. Dara Zirofsky, and/or Dr. Karen Brantman, to provide medical care for my pet(s): Date: (required) Please print first and last name: (required)