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

  • Patient History

  • Fleas 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 above to acknowledge you have read our payment policy. The form will not be submitted unless you have checked this box.