New Patient Registration Form – Veterinary Dermatology Center

Welcome!

Please fill out our questionnaire and look for the confirmation at the end to ensure that you have submitted successfully. We recommend using a computer, as phones and tablets often result in an unsuccessful submission. A staff member will contact you within 3-7 business days to schedule your pet for a new patient appointment.

Today's Date

MM

DD

YYYY

Format: mm/dd/yyyy

Primary Owner*

First Last

Spouse/Secondary Owner

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Is this a a mobile phone?*

Email Address*

Primary Language Spoken:*

Which forms of communication can we use to contact you? (check all that apply)*

Select All
Phone
Text
Email

Work Phone

Spouse/Secondary Phone

Patient's Information

Pet's Name*

Species*

Canine
Feline

Species

Breed*

Date of Birth or Age*

Color*

Sex*

Male
Female

Spayed/Neutered?*

Yes
No

For the safety of our staff and your pet, is there anything special we should know about your pet's temperament while at the vet? (For example: he needs to be muzzled for treatment, she does not like having her feet touched, etc.)*

Has your pet ever had a seizure?*

Yes
No
Unsure

Does your pet have any known allergies to any medications?*

Has your pet been diagnosed with any other medical problems other than skin or ears?*

Please list current medications:*

Referral Information

Veterinarian(s) seen over the past 6 months to a year:*

*If you were not referred to us, please include your pet's regular veterinarian information (veterinarians you have seen over the past 6-12 months). If you're not sure, please write that in the designated field.

Name of Hospital/Clinic*

Additional Hospitals/Clinics:

Patient History

How old was your pet when s/he was obtained?*

Where was your pet obtained?*

Shelter
Pet Shop
Private Breeder
Other

Has your pet lived/traveled outside of Central Florida*

Describe the reason for your visit to our office:*

When did you first notice this condition (approximately)?*

Onset:*

Sudden
Gradual

Is the problem continual or intermittent?*

Continual
Intermittent

Is the problem worse indoors, outdoors or doesn't matter?*

Indoors
Outdoors
Doesn't matter

Is the problem worse at certain times of year than others? If so, when?*

Spring
Summer
Fall
Winter
No change throughout the year

Does the pet scratch, chew, itch, bite, lick, groom excessively or none of these (check all that apply)*

Scratch
Chew
Itch
Bite
Lick
Groom Excessively
None of these

If yes, how severe is the itching problem?

Mild
Moderate
Severe

Where on the body?

Is there hair loss?*

Yes
No

Describe location of hair loss (check all that apply)

Are there changes in the color of hair or skin?*

Hair
Skin
No color changes

If there are color changes, please describe them

Does your pet have any signs/symptoms you feel are abnormal?

Describe the treatment your pet has received for their skin problem? Include your pet's response to treatment and for how long.*

Is your pet receiving treatment/medications now for their skin/ear issue? If so, what kind? When was the last dose/treatment administered?*

Has your pet been kenneled/boarded?*

Yes
No

If yes, when?

How often do you bathe your pet? What shampoo do you use?*

Does your pet go to a groomer?*

Yes
No

If yes, how often?

What other pets are in your house?*

Dogs
Cats
Birds
Other
None

Do the other pets have skin problems?*

Yes
No
Not applicable

Do any people in the home have skin problems?*

Yes
No

Describe the pet's diet (brand and type of food)*

Is the pet mostly indoors, outdoors or in and out?*

Indoors
Outdoors
In and out

What does your pet contact indoors in terms of rugs, bedding, carpet deodorizers, cigarette smoke, etc.?*

What is your pet in contact with outdoors in terms of grass, weeds, plants (e.g. Wandering Jew, Jasmine, etc.)?*

Briefly describe your pet's environment (e.g. weeds, rural, suburban, urban):*

Heartworm and Flea Prevention

What heartworm prevention is your pet taking?*

Does your pet ever have fleas or ticks?*

Yes
No
Don't know

If yes, when was the last time you saw a flea on your pet?

What flea treatment is your pet receiving?*

How often?

What kind of flea treatment are you using in your yard*

How often?

What kind of flea treatment are you using in your house?*

How often?

How did you hear about us?

How did you hear about the Veterinary Dermatology Center?*

Extra Label Use Policy information*

Extra-Label Drug Use refers to the use of an FDA-approved drug in a manner not specifically described on the drug label, including but not limited to use in a different species, at a different dosage, frequency, route of administration, or for a different medical condition. I understand and acknowledge that my veterinarian may determine that extra-label drug use is medically appropriate for my animal based on their professional judgment and the animal’s specific condition. I understand that such use is legal and common in veterinary medicine (AMDUCA) when there is no approved drug available or when extra-label use is deemed to be in the best interest of the animal. I acknowledge that the potential risks, benefits, and alternatives associated with extra-label drug use have been explained to me to the extent reasonably possible, and that outcomes cannot be guaranteed. I consent to the use of extra-label medications as deemed necessary by my veterinarian for the diagnosis and/or treatment of my animal. I agree to follow all dosing and administration instructions provided and understand that failure to do so may increase the risk of adverse effects or reduced treatment effectiveness.

I have read and understand the Extra Label Use policy information.

Payment Policy Information*

Cashless Practice: Only major credit cards and CareCredit are accepted. Payment Timing: • Payment is due in full at the time services are rendered. Pet Insurance: • We can provide documentation to file a claim for reimbursement if you have pet insurance. New Patient Deposit: • A $235 deposit is required to book a new patient appointment. • This deposit goes toward your first visit. • If you do not cancel at least 48 hours in advance, the deposit is forfeited.

I have read the Veterinary Dermatology Payment Policy

New Patient Questionnaire

Welcome!

Patient's Information

Referral Information

Patient History

Heartworm and Flea Prevention

How did you hear about us?