Pet Owner InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Primary Vet Pet Medical HistoryPet's Name* 1. Is your pet current on all vaccinations?* Yes No 2. Is your pet taking heartworm preventative medication?* Yes No 3. Has your pet traveled outside of New York?* Yes No Where and when?4. Does your pet have any significant medical problems other than the eye(s)?5. Are you currently treating your pet with any medications?* Yes No If medications are being given, please list name(s), amount and frequencies:6. Is your pet diabetic?* Yes No Amount of insulin given:Eye Problems7. What leads you to believe your pet has an eye problem?Loss of vision More in dim light or bright light Eye discharge Watery Like pus Thick and green Peculiar color to the eye(s)? Yes No Please describe:Holds eye(s) closed Yes No Veterinarian noted the problem Yes No 8. How long has the problem been present?9. How well do you believe your pet sees?* Excellent Poor on all occasions Poor especially in: Dim light Bright light Poor in regard to: Near Distant objects Poor in regard to: Moving Stationary objects 10. Do you have other pets?* Yes No Name the type of pet(s) and whether or not they have eye problems:11. Do you know your pet's dam or sire or littermates?* Yes No Do any of them have eye problems? Yes No Don't know 12. Are you in the medical field?* Yes No You are a: Physician Dentist RN Comments/Questions
