New Patient Form for Animal Dermatology Group

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Home
Find a Clinic
Request an Appointment
New Patient Form
New Client Form
International
Dermatopathology
All Locations
Services
Education
Pharmacy
About Us
Careers
State Locations
California
- Marina del Rey
- Ontario
- Pasadena
- San Diego
- Tustin
- Bakersfield
- Long Beach
- Los Gatos
- Mission Viejo
- Murrieta
- Palm Desert
- Torrance
- Rocklin
Florida
- Bradenton
- Bonita Springs
Georgia
- Marietta
- Savannah
Indiana
- Indianapolis
- Evansville
Kentucky
- Indianapolis
- Evansville
Nevada
- Las Vegas
New Jersey
New York
- White Plains
- Rockland County
North Carolina
- Charlotte
- Hickory
- Huntersville
- Denver
Oregon
- Portland
- Lake Oswego
South Carolina
Texas
- Austin
- Round Rock
- Dallas
- Grapevine
Washington
- Vancouver
- Lynnwood

New Patient Form

Please complete the form below after calling to make an appointment. If you encounter problems completing the form, please download a blank form, complete it and bring it with you on the day of your appointment.

*If your clinic location is not listed in the "Clinic" drop down menu in form below, please find separate button link for your clinic's patient form below form. These locations include: Wayne, White Plains, Rockland, Dallas, Grapevine, Mt. Pleasant, Greenville, Charlotte, Columbia, Lynnwood, & Round Rock.

To download Adobe^® Acrobat Reader Click Here.

If you would prefer to download a blank form to complete and print manually, Click Here.

Client Information

First Name* Last Name* Email* Add email to Enews list?

Phone* Clinic*

Pet

Name of Pet* Date of Birth (approx)* Date Acquired (approx)* Spayed/Neutered? If spayed/neutered, provide date

Condition

Reason(s) for Visit* Date Problem Started (approx)* % of Time Pet Is Indoors (0-100) Condition Currently Seasonal?*

seasonal continuous

Was Condition Initially Seasonal?*

yes no

Is There a Time Disease is Less Severe? (If so, explain) Occasions Symptoms are Worse? indoors outdoors morning night

Please Explain Occasions Symptoms are Worse.

Onset and History of Symptoms

First indications of problem? hair loss rash pimples redness normal skin, but itchy

Where did the problem start? nose ears neck back rump tail front legs front paws back legs back paws eyes chest abdomen groin

Does pet scratch, rub, check, lick or bite any of these areas? nose ears neck back rump tail front legs front paws back legs back paws eyes chest abdomen groin muzzle armpits inner legs and thighs

Progression

Has the Problem Spread? (if so, explain) How Itchy Is Your Pet?* (10 being most severe)

1 2 3 4 5 6 7 8 9 10

Does your pet exhibit any of the following?

If you select a symptom, please list frequency and description

Cough Runny Nose Diarrhea Loss of Appetite Urinate Excessively Sneeze Ear Infections Vomit Drink Excessively Limp

Additional Details of Symptoms

Household/Environment Details

(If Any Item Selected, Please Explain)

Do You Have Other Pets?
Are Other Pets In Home Affected by Condition?
Are Pets Littermates or Parents Affected by Condition? Do Any People In Your Home Have Skin Problems?

Flea Control / Bathing

Use Flea Control on Pet? (explain type and and frequency) Use Environmental Flea Control in Home or Yard? How Often do you Bathe Your Pet?* Shampoos or Bathing Products*

Diet

Describe Foods and Treats* How Long On This Diet?* Vitamins or Supplements? Bowel Movements Per Day*

1 2 3 4 5 6

Previous Treatments

Any Medications or Injections Used For Skin Condition Any Other Pet Medications Have Any Medications Helped The Condition? How Many Times Has Pet Been Treated for Condition?*

0 1 2 3 4 5 6

Has Pet Been Treated for Stomach or Intestinal Problems?

Your Comments

Additional Information or Comments For Our Veteriniarians * = required fields

*If your clinic location is not listed in the "Clinic" drop down menu in form above, please find separate button link for your clinic location below.

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