New Patient Registration Form – Veterinary Dermatology Center

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*

Is this a a mobile phone?*

Email Address*

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*

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 or ears?*

Please list current medications:*

Referral Information

Referring Veterinarian:*

*If you were not referred to us please include your pet's regular veterinarian information. 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?*

Payment Information*

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 below to confirm you have read our payment policy. Your form will not be submitted unless you have checked this box.

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?