Animal Dermatology Clinics

New Patient Form

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Client Information



Pet
If spayed/neutered, provide date

Condition

seasonal  continuous 

yes  no 

indoors  outdoors  morning  night 

Onset and History of Symptoms

hair loss  rash  pimples  redness  normal skin, but itchy 

nose  ears  neck  back  rump  tail  front legs  front paws  back legs  back paws  eyes  chest  abdomen  groin 

nose  ears  neck  back  rump  tail  front legs  front paws  back legs  back paws  eyes  chest  abdomen  groin  muzzle  armpits  inner legs and thighs 
Progression
(10 being most severe)
1  2  3  4  5  6  7  8  9  10 
Does your pet exhibit any of the following?
If you select a symptom, please list frequency and description

Additional Details of Symptoms

Household/Environment Details

(If Any Item Selected, Please Explain)



Flea Control / Bathing
Diet
1  2  3  4  5  6 

Previous Treatments

0  1  2  3  4  5  6 

Your Comments

* = required fields

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