New Patient Forms in Lacey, WA | Dermatology Clinic for Animals

Owner #1 Name

First NameLast Name

Owner #1 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please indicate

Can we send you text messages?

Owner #2 Name

First NameLast Name

Owner #2 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please indicate

Can we send you text messages?

REQUIRED FIELD: Address - NO P.O. BOXES - this must be a physical address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

May we contact you by Email?

Email

example@example.com

Employer

REQUIRED FIELD: BEHAVIORAL HISTORY: Has your pet ever bitten a person or veterinary staff member at a veterinary visit?

REQUIRED FIELD: If you answered yes, please explain with as much detail as possible. If you answered no, please advise whether your animal has been in social situations where the opportunity would have presented itself to show aggression towards another animal.

REQUIRED FIELD: Does your pet have a history of biting/attacking other dogs or cats, either at home or at the veterinary hospital?

REQUIRED FIELD: If you answered yes, please explain with as much detail as possible. If you answered no, please advise whether your animal has been in social situations where the opportunity would have presented itself to show aggression towards another animal.

REQUIRED FIELD: Has your pet ever been prescribed oral or injectable sedation for use prior to or during veterinary visits for the purpose of controlling anxiety/fear or aggression? (biting, snapping, growling, alligator rolling, guarding you/protective of you during exams)

REQUIRED FIELD: If you answered yes, please explain with as much detail as possible. Which types of behaviors have been displayed. If you answered no, please advise whether your animal has been in social situations where the opportunity would have presented itself to show aggression towards another animal.

REQUIRED FIELD: Has your veterinarian required your pet to wear a muzzle in the hospital?

REQUIRED FIELD: If you answered yes, can you tell us what type of muzzle was used? Please explain with as much detail as possible. If you answered no, please advise whether your animal has been in social situations where the opportunity would have presented itself to show aggression towards another animal.

Please disclose all prior veterinary facilities you have taken your pet. This includes and is not limited to your current clinic of care, any specialty practice, holistic veterinary care, telehealth service, emergency clinic. * If you go to a VCA/Banfield please be specific which location you go to.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet Information

Main Complaint(s)

Age of pet when you acquired him/her:

What is pet's current age?

When did symptoms first begin? When did they worsen?

Is it seasonal or continuous?

If the problem was initially seasonal, which season(s)?

Is there a time/season when disease is less severe or the itching is less intense?

Has your pet traveled and/or lived outside of the Pacific Northwest (Washington, Oregon, Idaho)? If so, please list the geographical locations and the dates your pet was located outside of the area.

What did the problem look like initially? (Please check a box)

Where did it start? (Please check)

Has it spread?

If so, where?

Does your pet scratch, rub, chew, lick, or bite the following? (Please check a box)

If so, where?

Was the itching the first thing noticed?

Percent of time pet is confined indoors (%)?

Percent of time pet is Outdoors (%)?

What is your primary indoor flooring surface?

Where/when are symptoms the worst?

If a female, are or were there normal heat cycles?

If a male, does he have normal interest in females?

Do any relatives of your pet have any skin problems that you are aware of?

If yes, explain:

Do you use flea control?

If so, when was it last given?

What brand do you use and how often (in weeks)?

Lastly, are other pets in the household on flea control?

Do you use insecticides in your home?

Frequency?

Do you use insecticides in your home?

Is your pet exposed to tobacco smoke?

Please check each box of list of medications that your pet has been on for the problem.

Apoquel

Cytopoint

Antihistamines

Steroid pills

Steroid shots

Antibiotics

Antifungal

If other, please list

Other

Did any of the medications above help the problem?

If yes, which ones helped?

Is your pet currently on any other medications, vitamins, or food supplements?

If so, what are they?

What is your pet’s regular diet (brand, ingredients, protein source i.e.: Chicken, Lamb, Pork, Beef, Salmon, etc.)?

Has your pet ever been on a prescription hypoallergic diet trial? If yes, what diet and for how long? Any other foods or treats given? What flea/heartworm preventative was your pet taking at the time?

How often do you bathe your pet?

What shampoo and/or conditioner do you use?

Do you flush ears; if so, with what?

Does your pet have any other health problems?

Please Explain Runny Eyes

Runny eyes

Please Explain Cough

Cough

Please Explain Sneeze

Sneeze

Please Explain Vomiting

Vomiting

Please Explain Diarrhea

Diarrhea

Please Explain Loose Stools

Loose stools

Please Explain Frequent defecations (4+ / day)

Frequent defecation (4+/day)

Please Explain Increased Flatulence

Increased flatulence

Please Explain Burping (gurgling stomach)

Burping “gurgling stomach”

Please Explain Regurgitation

Regurgitation

Please Explain Limping/Arthritis

Limping/arthritis

Please Explain Excessive Drinking

Excessive drinking

Please Explain Excessive Urination

Excessive urination

Please Explain Excessive Hunger

Excessive hunger

Please Explain Excessive Panting

Excessive panting

Please Explain Weight Gain

Weight gain

Please Explain Weight Loss

Weight loss

Please Explain Heat Intolerance or "slowing down"

Heat intolerance or “slowing down”

Please Explain Other

Other, please explain

Does your pet frequent the following facilities? (Groomers)

If so, how often at the Groomers?

Groomers

Does your pet frequent the following facilities? (Daycare)

If so, how often at Daycare

Daycare

Does your pet frequent the following facilities? (Dog Park)

If so, how often at the Dog Park?

Dog Park

Does your pet frequent the following facilities? (Veterinary Hospital)

If so, how often at the Veterinary Hospital?

Veterinary Hospital

Do you have other pets? Specifically, cats, dogs, birds, small mammal exotics (rabbits, ferrets, rodents, etc.)? If yes, describe. Do any of these animals have skin problems? If yes, explain.

Do any people in the household have skin problems? If yes, explain

How did you hear about DCFA?

Signature

Once you click Submit, please do not close your browser. An additional form will populate that is required to be completed before scheduling your pet's initial evaluation.

New Patient Form

Owner Information

Pet Information

Patient History