New Patient Form: Dermatology

If your pet has an upcoming dermatology appointment with Dr. Tina Brown, please complete the specialty form using one of the options below.

OPTION 1
Complete Online

Complete and submit the form below.

OPTION 2
Print & Complete

Bring the completed form with you.

Download PDF

OPTION 3
Complete on Arrival

If you prefer, you can complete the form when you get to our hospital.

Dermatological History

We appreciate your cooperation in providing us with the following information.

Client First Name *

Client Last Name *

Email *

Phone *

Pet's Name *

Describe your pet's skin problem. *

When did the problem first appear? *

What the onset gradual or sudden? *

Describe the problem as it first appeared. *

What parts of your pet were first affected? *

Has your pet always lived in this part of the country? *

If no, please explain.

From where did you obtain your pet? *

How long have you had your pet? *

Where does your pet spend most of its days? *

Describe the indoor environment of your pet (such as pet's bedding, where it sleeps, etc.) *

Describe the outdoor environment of your pet (grasses, weeds, wooded areas, etc.) *

Which of the following best fits your pet's skin problem? *

Is there a relationship between the severity of your pet's skin condition and the season of the year? *

If yes, please explain.

Which of the following does your pet do excessively (Choose all that apply). *

Chew

Bite

Lick

Rub

Scratch

Other

None

All of the above are signs of itching. Please rate the level of itching on a scale of 1 to 10 (10 being severe)

If present, what are the primary areas that your pet licks, chews, rubs or scratches.

Was itching the first sign of your pet's skin disease that you noticed. *

If no, what were the first signs you noticed?

Has your pet ever had ear problems? *

If yes, please explain.

Do you have any other pets? *

Please list any other pets.

Do any of your other pets have similar skin conditions?

Do any pets in the neighborhood have a similar problem? *

Are you aware of any relatives of your pet having a similar problem? *

Has anyone in your household had skin problems since your pet was affected? *

Have you noticed fleas on your pet? *

Do any other pets in your household have fleas?

Do you use flea products on your pet to control fleas? *

If “yes,” please list what you use.

Frequency of application

What treatment has your pet received for the skin problem? If possible provide drug names, dosages, and duration of treatment. *

Describe what response there was to this treatment.

Has your pet received cortisone or steroids? *

If “yes,” which of the following was/were used?

When was it last given or applied?

Which medication was most effective at controlling your pet’s skin problem?

Please list the current medications you pet is receiving.

Have you been using any home remedies for your pet’s skin condition? *

If “yes,” please describe.

Does your pet have any other previously diagnosed medical or surgical problem that is unrelated to the skin disorder? *

If “yes,” please describe.

Medications used for this problem.

Have you noticed any changes in the health or behavior of your pet coincidental with the development of the skin condition? *

If “yes,” please describe.

Describe the diet of your pet.

Has your pet been boarded in the past 2-3 months?

Has your pet been to the groomer or day care in the past 2-3 months?

What heart worm preventative do you use for your pet?

Thank You!

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From Our Clients

"We were very impressed with everyone on staff. We ended up having to euthanize our sweet dog because of an injury resulting in paralysis. The staff was very sensitive to our situation and offered their condolences several times. The staff explained every option to us including costs. We found them all to be very professional and caring. I would definitely recommend this clinic to anyone needing emergent care for their pet."
Shelley M.

New Patient Form: Dermatology

OPTION 1Complete Online

OPTION 2Print & Complete

OPTION 3Complete on Arrival

Dermatological History

Thank You!

From Our Clients

OPTION 1
Complete Online

OPTION 2
Print & Complete

OPTION 3
Complete on Arrival