Date

Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Date of Birth *

Employer *

Occupation *

Secondary Owner's Employer

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

No

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

By listing your primary care veterinarian, you are authorizing Animal Friends Dermatology to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

Tell Us About Your Pet's Skin/Ear Issue

Describe your pet’s skin/or ear problem *

How long has the skin/or ear problem been present? *

How old was your pet when any skin or ear problem first appeared? *

Was the onset of your pet's condition gradual or sudden? *

Gradual

Sudden

Is there a relationship between the severity of the pet’s skin/ear condition and the season of the year? If yes, please which seasons? *

Does your pet exhibit any of the following behaviors? *

Chewing at an area

Biting at skin

Scratch self excessively

Licking excessively

None of the above

Other

If your pet exhibits behaviors listed above, or other behaviors that you are concerned about, please describe the body part affected. *

Was itching the first sign of your pet’s skin/or ear disease that you noticed? *

Yes

No

Had you moved with your pet prior to the problem starting? *

Yes

No

If you answered yes to the question above, where did you move from?

Where does your pet spend most of their day? *

Indoors

Outdoors

In-and-out

Describe the indoor environment of your pet (such as the pet’s bedding, where it sleeps, etc.) *

Describe the outdoor environment (grass, weeds, wooded areas, dirt, etc.) *

Please list any other pets. (species and number)

Do any of your other pets have similar conditions or symptoms?

Yes

No

Are you aware of any relatives of your pet having a similar problem? *

Yes

No

Have any people in your household had skin problems since your pet was affected? *

Yes

No

Have you noticed fleas on your pet(s)? *

Yes

No

If yes, what flea treatment was used on the pet or in the environment and has it helped?

Have you noticed any change in the health or behavior of your pet coincidental with the development of the skin/ear condition? If yes, please describe.

Does your pet have other previously diagnosed medical or surgical problems unrelated to the skin disorder? If yes please list.

Has your pet experienced any vomiting, diarrhea, loose or frequent stools, or changes in eating or drinking patterns? If yes, please describe.

What do you feed your pet? Please include brand and flavor of all dry food, wet food, and treats. Also include any table food your pet may get *

Please list all medications your pet is currently on. (Include any heartworm and flea preventatives, oral, topical, injectable medications, shampoos, conditioners, supplements, natural treatments, and any medication unrelated to skin/ear problem.) Also include strength, quantity, and frequency of medication.

Authorizations/Release

I hereby authorize and give my permission to Animal Friends Dermatology to use and reproduce photographs of my pet(s). I understand these photographs taken of my pet may be used in electronic or printed material for educational or promotional purpose only. Animal Friends Dermatology respects our client’s personal information and will not use any personal client information with regard to photographs or written material. *

Yes I authorize the use of images of my pet

No I do not authorize the use of images of my pet

Payment & Missed Appointments

By submitting this form, I hereby authorize Animal Friends Dermatology to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and I take it as my responsibility to comprehend any risks involved. I understand that payment is expected in full at the time services are rendered, and I assume full financial responsibility for all diagnostic and therapeutic procedures. I agree to make full payment for all services with cash, check, Visa, Mastercard, Discover, Care Credit or American Express. I agree to pay reasonable attorney’s fees and collection costs should collection become necessary.

By submitting this form I agree that I understand that Animal Friends Dermatology has the right to charge for canceled or broken appointments without 24-hour advance notice.

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