New Patient Appointment for Horses

If this is your horse's first time at one of our Northwest Animal Eye Specialists locations, please complete our New Patient Form.

Book An Appointment

My Horse 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 horse. Once you submit your information, you must contact your veterinarian(s) immediately and have them send your pet's medical records to us. Once we receive your pet’s records, our staff will review those as well as the information you've submitted in this form and will get back to you via email or phone within 2-3 business days or less with options for scheduling an appointment. 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. We are currently booking out by roughly 1-2 months for non-urgent new patient 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.

New Patient Appointment – Horses Form *

I acknowledge that I have read, understood, and agreed to the above statement.

Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner

Primary Phone *

Email *

What is your preferred method of contact?

Cell Phone - Call

Cell Phone - Text

Address *

City *

State *

Zip Code *

Employer *

Occupation *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Are you a previous or current client?

Yes

Please list the veterinarian (s) that your horse sees

If your horse sees another specialist, please include them in the list

If your horse has seen more than one vet, which one referred you to NWAES?

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

Patient Information

Horse Name *

Birth Date / Age *

Breed *

Color *

Altered *

Yes

Gender *

What led you to believe that your horse has an eye problem? *

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? *

Which eye is affected? *

Right

Left

Both

Has the eye problem changed since you first became aware of it? *

Yes

If yes, how has it changed?

Have you treated the eye(s) with anything?

Yes

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: *

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? *

Yes

If yes, what type?

Has your horse suffered from any other illness? *

Yes

If yes, what type?

Has your horse ever traveled outside of Western Washington? *

Yes

If yes, where?

Is your horse located at your home address? *

Yes

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? *

Yes

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.

EXAMINATION APPOINTMENTS

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.

SURGERY APPOINTMENTS

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 $812.50 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 $5.50/mile round trip travel fee to cover our doctor’s travel time. Please ask BEFORE the appointment/examination if you have questions.

Payments returned from your bank due to non-sufficient funds will be subject to a returned check fee of $64.50 for each item returned.

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.

MEDICAL RECORDS

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.

INFORMED CONSENT

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 understand the policies above and that you agree to abide by its terms during our professional relationship.

I hereby authorize Dr. Victoria Jones, Dr. Dara Zirofsky, and/or Dr. Karen Brantman-Crosetto to provide medical care for my horse(s): *

Date *

Please print first and last name: *

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New Patient Appointment for Horses

My Horse Needs an Appointment

Owner Information

Emergency Contact

Patient Information

Consent for Treatment and Hospital Policies

New Patients Welcome By Referral