(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 & Zipcode: (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 Please list the veterinarian(s) that your horse sees. If your horse sees another specialist, please include them in the list. (required) How did you hear about us? If your horse has seen more than one vet, which one referred you to NWAES? (required) Scheduling of our horse patients is done on a case-by-case basis, so please give us an idea of your availability for an appointment: (required)
Tell us about your horse:
Horse’s name: (required) Breed: (required) Age, date of birth (if known): (required) Sex: (required) Male Female Altered: (required) Yes No Color: (required) What led you to believe that your horse 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 horse. Your horse'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 Has your horse had any other eye problems? (required) Yes No If yes, what type? Has your horse suffered from any other illness? (required) Yes No If yes, what type? Has your horse ever traveled outside of Western Washington? (required) Yes No If yes, where? Is your horse located at your home address? (required) Yes No if your horse is located somewhere other than your home address, please provide the address and name of facility: Are you able to trailer your horse? (required) Yes No Please list any additional information that you think we should know about you or your horse:
CONSENT FOR TREATMENT AND HOSPITAL POLICIES
WELCOME TO OUR PRACTICE
We are pleased to have the opportunity to work with you and your horse. We hope that this information will be helpful in making an informed decision regarding the services that we can provide. It is very important for you to carefully read this agreement so that we can discuss any questions you may have.
The majority of our time is spent caring for the eyes of small animals, primarily dogs and cats. Therefore, scheduling of our horse patients is done on a case-by-case basis.
Surgeries take place at a different time than the initial examination. Special arrangements must be made because the doctor and staff of Northwest Animal Eye Specialists do not perform general anesthesia on horses. A horse surgery facility must become involved under these circumstances. All horse surgeries need final confirmation and a 50% deposit 72-96 hours in advance of surgery day.
PAYMENT POLICIES AND FEES
You can expect to pay $655.50 for exams. This price allows for inclusion of the basic tests that might need to be performed as part of the assessment (fluorescein staining, intraocular pressure testing) and for the possible need for a lid block. The examination fee does not include more advanced diagnostic testing, medications, or procedures. Additionally, there is a $4.00/mile round trip travel fee to cover our doctor’s travel time. Please ask BEFORE the appointment/examination if you have questions.
PAYMENT FOR SERVICES PROVIDED FOR YOU AND YOUR horse IS EXPECTED AT THE TIME SERVICES ARE RENDERED. *ALL NEW PATIENTS WILL NEED TO PREPAY*
Acceptable forms of payment include cash, check, Visa, MasterCard, Discover or American Express. 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 follow the terms of their agreement. Insured horses: 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.
EMERGENCIES AND HOW TO CONTACT US.
We are at our main hospital between 9 AM and 5 PM Monday through Thursday. 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 our doctor on call.
Your horse’s medical records are confidential. Information about your horse’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. If you have a concern about this policy, it needs to be discussed before the examination appointment. Keep in mind that we try to work as part of a healthcare team with your regular veterinarian.
By providing your name below and authorizing our staff to provide care for your horse, 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 horse(s): Date (required)
Please print first and last name: (required)