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.
What is the problem with your pet's eye(s):
Which eye is affected? Left
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):
Sudden change in vision
Slow change in vision
Rubbing At The Eyes
Discharge From The Eyes (check all that apply): Watery
Please check if your pet is having any of the following:
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?
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Iodine 131 Therapy
5425 Victory Drive | Indianapolis, IN 46203P: 317-782-4484 | TF: 800-551-4879© Site Map