Animal Dermatology Clinics - New Patient Form

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? (if so provide date)

Condition

Primary Complaint(s)*

Date Problem Started (approx)*

% of Time Pet Is Indoors (0-100)

Is 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 If Occasions Symptoms are Worse.

Onset and History of Symptoms

First indications of problem?

hair loss rash pimples redness normal skin, but itchy

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

Household (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?

Additional Information or Comments For Our Veteriniarians

* = required fields

Client Information

Calendar of Events

Locations

Pollen Forecast

New Patient Form

Client Information

Pet

Condition

Onset and History of Symptoms

First indications of problem?

Where did the problem start?

Does pet scratch, rub, check, lick or bite any of these areas?

progression

Does your pet exhibit any of the following? (If you select a symptom, please list frequency and description)

Additional Details of Symptoms

Household/Environment Details

Household (If Any Item Selected, Please Explain)

Flea Control / Bathing

Diet

Previous Treatments

Additional Information or Comments For Our Veteriniarians

For Veterinarians

For Veterinarians

Client Information

Calendar of Events

Locations

Pollen Forecast

New Patient Form

Client Information

Pet

Condition

Onset and History of Symptoms

First indications of problem?

Where did the problem start?

Does pet scratch, rub, check, lick or bite any of these areas?

progression

Does your pet exhibit any of the following? (If you select a symptom, please list frequency and description)

Additional Details of Symptoms

Household/Environment Details

Household (If Any Item Selected, Please Explain)

Flea Control / Bathing

Diet

Previous Treatments

Additional Information or Comments For Our Veteriniarians