Name* First Last Phone*Email* What is your preferred means of communication?* Call Text EmailCurrent Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Pet's Name*Pet's AgePet's BreedSex*Please Select OneMaleMale – NeuteredFemaleFemale – SpayedCurrent Veterinary Clinic*Veterinarian’s name, if known.How did you hear about us?What are the concerns about your pet?*Check all that apply Dandruff or Crusts Ear Problem Hair Loss Itching Odor Oily Skin Pigment Change Rash or Redness OtherOther, please specify.At what age did you first notice the problem?On a scale of 1-10 (1: normal; 10: severely itchy), how itchy is your Pet?Did it start suddenly or gradually? Suddenly GraduallyWhere did the problem start?Check all that apply Abdomen Chest Ears Face Tail Trunk Paws and Legs OtherOther, please specify.Does your pet itch more when outside? Yes NoDuring what seasons does your pet itch the most?Check all that apply Not Itchy All seasons are equal Fall Spring Summer WinterWhere does your pet spend most of his/her time? Indoor OutdoorWhat is your pet’s current diet, including treats?Have you completed a strict 6+ week diet trial to rule out food allergy? Yes NoHow often do you bathe your pet and when was their most recent bath?List most recent bathing products used.What treatments have temporarily helped the problem? Antibiotics Flea Control Prednisone Steroid Injection Topical Therapy Apoquel Cytopoint (CADI) Atopica OtherOther, please specify.What treatments have not helped the problem? Antibiotics Flea Control Prednisone Steroid Injection Topical Therapy Apoquel Cytopoint (CADI) Atopica OtherOther, please specify.List all current medications, supplements, and treatments your pet is receiving.What flea control products do you use? Frontline Frontline Plus Advantage Advantage Multi Advantix Seresto Collar Revolution Comfortis Trifexis Bravecto Nexgard Simparica OtherOther, please specify.Are there other pets in the home with a skin or ear problem?* Yes NoIf yes, please explain.*Are there any family members who have an unexplained skin problem?* Yes NoIf yes, please explain.*Has your pet traveled outside the area?* Yes NoIf yes, please explain.*Does your pet eat, drink, urinate and defecate normal amounts?* Yes NoIs your pet allergic to any medications?* Yes No/UnknownDoes your pet have additional medical conditions?* Yes NoIf yes, please explain.*Payment is due at the time services are provided. For your convenience we accept cash, personal checks, VISA, Master Card, Discover, American Express and CareCredit. Prescription medications require a current veterinary-client-patient relationship. In order to ensure all medications we dispense have been properly stored and handled, we do not accept returns. SkinVet Clinic is limited to dermatology. We will routinely provide your primary veterinarian with our findings and recommendations. Please inform our Care Coordinator if you would like your pet’s records to be available only to SkinVet Clinic’s staff. Your primary care veterinarian should be consulted for all other pet care health concerns. A Veterinarian is not on the premises of SkinVet Clinic on Saturdays or Sundays. Your primary care veterinarian or an animal emergency clinic should be contacted in case of emergency during these times. Our Care Coordinator would be happy to provide you with a contact phone number to a local emergency clinic. Thank you for choosing SkinVet Clinic for your pet’s dermatology needs. We look forward to building a lasting relationship with you and your pet and helping improve your pet’s quality of life.Signature*Date* MM slash DD slash YYYY CAPTCHAΔ
