Forms

Canine dermatology history form

Please fill out and submit this form before your scheduled appointment time.
BE SURE TO BRING THE PREVIOUS MEDICATIONS, PILLS, OINTMENTS, EAR CLEANERS, SHAMPOOS, EVEN IF EMPTY TO THE CONSULTATION. BRING FOOD AND TREAT INGREDIENT LABELS.
DO NOT BATHE YOUR DOG WITHIN 5 DAYS, DO NOT CLEAN OR TREAT EARS WITHIN 2 DAYS OF YOUR DOG'S APPOINTMENT.

* Indicates required field

Your Name *

Pets Name *

Pets Age *

Pets Breed *

Sex *

Primary Concerns about your dogs skin. *

When was this first noticed? *

Was this onset rapid or gradual? *

Does the pet itch? *

Rate your pets itch (10-constant severe itching all day and night, 0-no itching) *

What time of year is your pet most itchy? *

Where does your dog spend time? *

Are there other pets in the home, if so how many? *

Do any people in the house have skin problems or itching? *

If yes, do these pets have skin problems or itching? *

What is the name of your dog's food? *

What treats or table food does your dog eat? *

What flea control do you use and how often? year round? *

If there are other pets in the home do they get flea control at the same intervals? *

How often do you bathe your pet? *

What medication is your pet taking at this time? *

What previously prescribed medications have helped your pet? *

What other health problems does your dog have? *

Please share any additional information that you think is important for us to know: *

How often does your dog swim? *

Submit