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New Patient Information Form
Complete the form below prior to your first visit!
Please enable JavaScript in your browser to complete this form.
Owner's name
*
First
Last
Email
*
Pet's name
*
Date of birth or approximate age
*
Sex
*
Female, spayed
Female, intact
Male, neutered
Male, intact
Type of pet
*
Dog
Cat
Breed
*
Color
*
Does your pet have pet insurance for skin and ear disease?
*
Yes
No
Please provide the insurance company name that we will forward exam summaries to:
*
Is your cat indoor, outdoor, or indoor/outdoor?
*
Indoor
Outdoor
Indoor/outdoor
Please list all veterinary offices visited in the past three years
*
How long have you owned your pet?
*
Please provide in chronological order cities or states or countries your pet has lived? (ex: If only Los Angeles only write: LA Only)
*
What skin or ear problem are you bringing your pet in for?
*
How long has the problem been present?
*
Does your pet do any of the following? Click all that apply.
Get ear infections
Cough
Runny nose
Sneeze
Diarrhea
More than three bowel movements a day
Overly gassy
Scoot (drag bottom on ground)
Loss of apetite
Vomiting more than once per month
Feces with tapeworms (white rice grains)
Drink excessively
Urinate excessively
Limp
If yes to any of the above, please list frequency and description.
*
How old was your pet when the problem first started?
*
When the problem first started, it began:
*
Suddenly
Gradually over a period of time
Does your pet scratch, rub, lick, chew, or bite any of the following areas?
Nose/muzzle
Eyes
Back paws
Front paws
Chest
Back
Front legs
Back legs
Tail
Abdomen
Rump
Ears
Armpits
Inner thighs and legs
The problems have been:
*
Continuous but better with medication
Continuous, no better with medication
Intermittent or sporadic
Is the problem worse during certain times of year?
*
Yes
No
When?
*
Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease?
Selected Value:
0
(0-no scratching ever, 1-occasional scratch, 10-constant, severe scratching)
How itchy has your pet been over the last month?
Selected Value:
0
(0-no scratching ever, 1-occasional scratch, 10-constant, severe scratching)
Is your pet currently taking any medication?
*
Yes
No
Medication name
*
Medication dosage
*
Did any of the medications help the problem?
*
Yes
No
If so, which ones?
*
What diet do you feed your pet currently?
*
Within an hour of eating does your pet lick its lips excessively, or have ears, face or paws turn red and itchy?
Yes
No
How many bowel movements does your pet have per day?
*
Have any diets been tried as treatment?
*
Yes
No
If yes, which ones and how long were they given?
*
Has your pet been treated for stomach or intestinal problems?
*
Yes
No
Please explain.
*
How often do you usually bathe your pet?
*
What shampoo do you use?
*
When was the last time you saw a flea on your pet?
*
What flea, tick, and heartworm prevention products are you using on your pet?
*
Please list type(s) and last time it was given
Do any other pets or humans in the household have skin problems?
*
Yes
No
Please explain.
*
What other pets are in the household?
*
Other than skin disease, does your pet have any diagnosed medical problems?
*
Yes
No
Please explain.
*
Do you or a family member work in the health care field?
*
Yes
No
What is the occupation?
*
Are there any other symptoms that your pet has that have not been described above, or is there anything else you think might be contributing to your pet's skin or ear disease?
*
Email
Submit
