Dermatology Admission Form

Your Email*

Would you like to receive updates, news and articles via Email?*

Yes
No

Pet's Name*

Breed*

Canine or Feline?*

Canine
Feline

Sex*

Neutered Male
Intact Male
Spayed Female
Intact Female

Age*

Color*

Weight*

Skin problems*

What skin problem are you bringing your pet in for?

Age when issue was detected*

How old was your pet when the skin problem first started?

Suddenly or gradually?*

Did the problem start suddenly or gradually over time?

Year Round or Intermittent?*

All Year Round
Intermittent

Seasonal Flare-Ups?*

Yes
No

Is the problem worse during certain times of the year?

If yes, when?

Spring
Summer
Fall
Winter

Check all that apply

Ear Infection?*

Yes
No

Has your pet ever had an ear infection?

If yes, what time(s) of the year?

Spring
Summer
Fall
Winter

Check all that apply

Itchy?*

Yes
No

Is your pet itchy (this includes any licking, chewing, rubbing, biting, or scratching)?

Rate the Itching (Scale of 0-10)

Rate your pet’s level of itch on a scale of 0 (no itch) to 10 (your pet’s most severe itch). Write a number 1 to 10 here

Locations of Itching on Body

List the locations on your pet’s body where they are itchy

What did you notice first?

Skin Lesions
Itch
Both

What did you notice first (choose one)?

Current Medications

List ALL medications your pet is CURRENTLY taking (including any topicals, supplements, or medications for other conditions not related to the skin). Indicate the response to these treatments if known.

Past Medications

List PREVIOUS medications used to treat your pet’s skin/ears (including any topicals or supplements). Indicate the response to these treatments if known.

Indoors or Outdoors?

Indoors
Outdoors
Both

Is your pet primarily (choose one)

Flea / Tick Prevention Q1

What flea/tick prevention are you using?

Flea / Tick Prevention Q2

Year Round
Seasonally

When is the flea / tick prevention given?

Heartworm Prevention Q1

What heartworm prevention are you using?

Heartworm Prevention Q2

Year Round
Seasonally

When is the heartworm prevention given?

Other Pets Q1

What other pets are in the household?

Other Pets Q2

Indoor
Outdoor
Both

Are the other pets primarily?

Other Pets Receiving Flea / Tick Prevention?

Yes
No

Are the other pets in the household receiving flea/tick prevention?

What type?

What type of flea / tick prevention do the other pets get?

Any Other Animals?

Does your pet have contact with any animals outside of your home (list location and types of animals)?

Others in Household with Skin Problems?

Yes
No

Do any other pets or people in the household have skin problems?

Pet Food & Treats

What do you feed your pet (include treats, chews, table food, etc.)?

Sensitive Stomach?

Yes
No

Does your pet have a sensitive stomach associated with feeding different types of food (ex. vomiting, diarrhea, etc.)?

Tried Other Diets?

Have different diets been tried as treatment (list brand name & duration given)?

Travel History

Does your pet have any travel history (list location)?

Other Medical History

List any other diagnosed medical illnesses.

Consent*

I hereby authorize the veterinarian to examine my pet and I understand that the initial consult and starting tests will total approximately $ 679.00 for my pets first visit with the Dermatology Service and I assume responsibility for all charges incurred. Additionally, if my pet should require further testing or hospitalization, I understand that a deposit will be required. I also understand that charges are to be paid in full upon completion of services. Should it be necessary to settle my account through a collection agency or attorney, I agree to pay any and all interest, collection costs, and legal fees.

How did you hear about us?*

CAPTCHA

Dermatology Admission Form

Client Services Center

Pay Your Invoice

Join Our Mailing List

The VMCLI is Now Offering
Stem Cell Treatments!

SERVICES

Side Widget Area

Dermatology Admission Form

Client Services Center

Pay Your Invoice

Join Our Mailing List

The VMCLI is Now Offering Stem Cell Treatments!

SERVICES

Side Widget Area

The VMCLI is Now Offering
Stem Cell Treatments!