2 Client

Client first name Client last name Client cell phone (able to receive texts)Client home phone (optional)Client email

Helios will contact the client directly to complete intake and booking.

3 Patient

Pet name Age or birthdate (DD/MM/YYYY)

Species Dog Cat Other

Sex MN FS M F

BreedCurrent weight (kg)

5 Clinical history

Ophthalmic diagnostics performed For each test, enter the result for the eye(s) tested, or tick “Not performed”.

Schirmer tear test (mm/min) Not performed

Fluorescein Not performed

Intraocular Pressure (mmHg) Not performed

Ocular medications prescribed (drug, dose, frequency, start date, response)Other current medicationsRelevant medical history (e.g., cardiac, endocrine, renal, hepatic disease)Known allergies or drug reactionsPrevious surgeries or anesthetic complications (including both routine surgeries and eye procedures)

Recent bloodwork Yes No

Behavioural or handling concerns Yes No

Brachycephalic or respiratory concerns Yes No

6 Attachments and follow-up

Upload files

Please attach at least one file: medical records, bloodwork, images, and other PDFs. Multiple files may be attached (PDF, JPG, PNG or HEIC; up to 5 files, 10.0 MB each and 50.0 MB in total).

Has the client been informed of this referral? Yes No

I confirm I can share the client’s contact details and the patient’s records with Helios Veterinary Vision for this referral (see our privacy policy).

Referrals are reviewed by our team before booking. Once approved, we will contact the client directly to schedule. Thank you for trusting Helios Veterinary Vision with your patient’s care.

Refer a patient.