Veterinary Dermatology Center
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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!
  • Format: mm/dd/yyyy
  • Note: mm/dd/yyyy
  • Patient's Information

  • Referral Information

  • *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.
  • Patient History

  • Heartworm and Flea Prevention

  • How did you hear about us?

  • 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.

Maitland Office (Main Office)

9901 N. Orlando Ave. (Hwy. 17-92)
Maitland FL 32751
Mon-Thurs: 8:00am-5:30pm | Fri: 8:00am-4:30pm

Rockledge (Satellite Location)

Animal Specialty & Emergency Hospital
5775 Schenck Ave Rockledge FL 32955
Wednesday & Thursday: 9:00am-3:30pm

© 2021 Veterinary Dermatology Center.
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  • Home
  • New Patients
    • What to Expect
    • Take A Tour
    • Why a Veterinary Dermatologist?
    • Patient Handouts
  • About Us
    • Team
    • Locations & Hours
    • Contact Us
    • Before and After Patient Photos
    • Testimonials
    • FAQs
  • Services
    • Medical Services
    • Allergy Testing
    • Food Allergy and Intolerance
    • Video Otoscopy
    • Anesthesia and Patient Monitoring
    • Flea Prevention and Control
    • Tick Prevention
    • Cutaneous Laser Surgery
  • Pet Health
    • Online Pharmacy
    • How-To Videos
    • News
    • FAQs
    • Links
  • Forms