IndyVet Emergency & Specialty Hospital

Ophthalmology Questionnaire

If you'd rather complete this form by hand, please click here, print the pdf, complete it and either bring it with you or fax it to 317-786-4484.

Name: Pet's Name:
Street Address:
City: State: Zip:
Email Address:
What is the problem with your pet's eye(s):
Which eye is affected? Left       Right       Both      
Has your pet had an eye problem or surgery prior to this one?
When did the current problem begin?
Have you noticed any of the following (check all that apply):
Redness     Cloudiness     Squinting     Sudden change in vision     Slow change in vision     Rubbing At The Eyes
Discharge From The Eyes (check all that apply): Watery       Clear       Thick       Yellow       Mucous
Please check if your pet is having any of the following:
Vomiting       Diarrhea       Coughing       Sneezing       Change In Appetite
Change In Drinking       Change In Urination       Change In Defecation      
Please list all medications and supplements that your pet is taking including those not for the eye. Please include the name of the medication (Ex. Ofloxacin), the route (Ex. Right/Left Eye), Frequency (Ex. 3x/day) and duration of use (Ex. 2 Weeks)
Do you have any additional concerns?
To help ensure the secure transmission of your information, please enter the text and numbers in the box in the area provided.

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5425 Victory Drive  |  Indianapolis, Indiana 46203  |  P: 317-782-4484  |  TF: 800-551-4879
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