Northwest Animal Eye Specialists

13020 NE 85th Street
Kirkland, WA 98033

(425)827-3966

www.northwestanimaleye.com

MY PET NEEDS AN APPOINTMENT

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 via email or phone within 2 business days 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. We recommend you use Google Chrome, Safari, or Mozilla Firefox to fill out this form. Please call us if you need assistance filling out this form.

Appointment Request Form


(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)

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
APPOINTMENTS:
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.
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.
DAY HOSPITALIZATION:
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.
MEDICAL RECORDS:
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.
INFORMED CONSENT:
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, Dr. Karen Brantman, and/or Dr. Jamie Schorling to provide medical care for my pet(s):
Date: (required)

Please print first and last name: (required)


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