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Veterinarians
Contact Us
- Contact Us
- Our Locations

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New Patient Sign Up

New Patient Sign Upadmin2025-03-25T16:29:37+11:00

BE A PART OF OUR VISION

Step 1 of 3

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Have you made an appointment with Animal Eye Care?(Required)

Yes

Client Information

Mrs

Miss

First Name:(Required)

Surname:(Required)

Address:(Required)

Suburb:(Required)

Postcode:(Required)

Mobile:(Required)

Landline:

Work:

E-mail(Required)

(for reminder letters – we will not contact you with advertising material or pass your details onto any third parties)

Co-Owner Info

Partner

Relative

Friend

Carer

First Name:

Surname:

Contact Number:

Patient Information

Pet's Name:(Required)

DOB/Age:(Required)

Colour:(Required)

Breed:(Required)

Sex(Required)

Male

Female

Desexed:(Required)

Yes

Pet's Weight (kg)(Required)

Have you been referred?(Required)

Yes

Your Usual Vet Clinic:

The Veterinarian You Normally See:

Please do not hesitate in speaking to any of our friendly staff members at Animal Eye Care if you have any questions or concerns during your visit here. Our aim is to provide the best experience and service at Animal Eye Care.

Do you have pet insurance?

Yes

Pet Insurance Co:

If you have Pet Insurance & require a claim form to be completed please speak to one of our friendly nurses prior to your consultation.

Patient History

How did you know that your pet had an eye problem?

Loss of vision

Cloudy eye(s)

Eye(s) held closed

Veterinarian noticed something

Discharge from eye(s)

Discharge Type

How long have the symptoms been present?

Which eye is affected?

Left eye

Right eye

Both eyes

Has the appearance of the eye changed since you first noticed the symptoms?

Yes

If yes, how?(Required)

How is your pet’s vision currently?

Excellent

Moderate

Poor in dim light, at dusk or in darkness

Poor on all occasions

What have the eyes been treated with?

What other medications is your pet now taking?

Does your pet have any other medical conditions?

Yes

If yes please specify:

Has your pet had a previous anaesthetic before (including desexing)?

Yes

Any previous / potential problems with the anaesthetic procedure?

Yes

If yes please specify:

Do you have other pets with eye problems?

Yes

If yes please specify:

How would you describe your relationship with your pet?

Family Member

Pet & Companion

Guard Dog

Working Dog

In Your Own Words:

Patient Behaviour

Does your pet mind having their face examined?

Yes

Has your pet shown any tendency to be aggressive or bite?

Yes

Would your pet require any of the following?

Muzzle

Sedation

Owner to hold only

Other

Authorisation

I acknowledge that the fees and charges are due for payment at the time of consultation or discharge. I acknowledge that Animal Eye Care does not provide accounts.

I will be settling my account by:

Cash

EFTPOS

Cheque

Credit Card

Date:(Required)

DD slash MM slash YYYY

Signature

Social Media

Please tick and sign below if you consent to images of your pet being used on our Instagram or FaceBook pages (we will inform you prior to anything being posted).

Tick here if you consent:

I consent to images of my pet being used on Animal Eye Care Instagram or FaceBook pages.

Date:(Required)

DD slash MM slash YYYY

Signature

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Animal Eye Care

Animal Eye Care was the first stand-alone specialist practice in Australia, established by Dr Robin Stanley in 1991. Robin’s vision was to be establish a clinic of Melbourne eye vets with a clear vision to provide the best care for all veterinary patients.

Contact

(03) 9563 6488
info@animaleyecare.com.au
181 Darling Road, Malvern East Victoria 3145 Australia

Opening Hours

Monday – Friday:
8:00 AM – 6:00 PM

New Patient Sign Up

BE A PART OF OUR VISION

Client Information

Co-Owner Info

Patient Information

Patient History

Patient Behaviour

Authorisation

Social Media

Animal Eye Care

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