New Patient Registration Form

New Patient Questionnaire

Please wait 24 hours to call the office at 407-629-0044 ext. 2 if you would like to verify that we have received your information.

Welcome!
Please fill out our questionnaire and look for the confirmation at the end. That way we ensure that you have submitted successfully. We recommend using a computer, as phones and tablets often result in an unsuccessful submission. We are looking forward to seeing you and your pet at your appointment!
Today's Date
MM
DD
YYYY

Format: mm/dd/yyyy
Appointment Date
MM
DD
YYYY

Note: mm/dd/yyyy
Primary Owner*
First Last
Spouse/Secondary Owner
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Alternate Phone
Can we contact you by email?*
- Yes
- No
Email Address*
Place of Employment
Work Phone
Spouse/Secondary Cell Phone
Patient's Information
Pet's Name*
Breed*
Age*
Color*
Sex*
- Male
- Female
Spayed/Neutered?*
- Yes
- No
For the safety of our staff and your pet, is there anything special we need to 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?*
Please list current medications; including heartworm and flea prevention:*
Referral Information
Referring Veterinarian:*
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:*
How long has it been present?
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?
- Face
- Eyes
- Ears
- Muzzle
- Neck
- Paws
- Tail
- Forelegs
- Hind legs
- Back
- Chest
- Belly
- Groin
- Anal area
Is there hair loss?*
- Yes
- No
Describe location of hair loss (check all that apply)
- Face
- Eyes
- Ears
- Muzzle
- Neck
- Paws
- Tail
- Forelegs
- Hind legs
- Back
- Chest
- Belly
- Groin
- Anal area
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):*
Fleas and Flea prevention
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?*
Payment Information*
- I have read the Veterinary Dermatology Payment Policy
The Veterinary Dermatology Center accepts cash, checks, and all major credit cards as forms of payment. We do NOT accept Care Credit at this time. Payment is due in full at the time services are rendered. If you have pet insurance, we are happy to provide you with the necessary documentation and assist in filing your claim for reimbursement. Please note that you are still responsible for paying the total charges at the time of your visit. We do not accept insurance discount cards. To finish submitting this form, please check the box above to acknowledge you have read our payment policy. The form will not be submitted unless you have checked this box.

New Patient Questionnaire

Welcome!

Patient's Information

Referral Information

Patient History

Fleas and Flea prevention

How did you hear about us?