Telemedicine — The Equine Eye Specialist

Telemedicine Examination Requests.

Please fill out this form to request a Telemedicine Examination. A member of our team will contact you within two business days to schedule your appointment.

Name of Horse

Breed

Age

Color

Sex

Owner Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Preferred contact method

(Call, text, or email)

Primary veterinarian name

First Name

Last Name

Primary veterinarian hospital

Primary veterinarian email

Primary veterinarian phone number

(###)

###

####

Patient diagnosis/history

Medications and frequency

Other info

(Optional)