New Client Patient Form: Dermatology

New Client Patient Form
Client Information
Pet Owner's Name

First NameLast Name
Pet's Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Communication Notice:

We send appointment reminders by text message and email. We also send financial statements by email and may call to discuss our veterinary services. By signing below, you consent to receive email, text, and phone calls from Animal Dermatology Group at the email address and phone number provided above. Note that text messages may be sent using automated dialing technology. Message and data rates may apply. Type “STOP” to cancel text messages and “HELP” for assistance. See our Privacy Policy for additional information.
Please list any person who is authorized to make medical and financial decisions regarding this patient:
Please list all veterinary offices visited in the past 2 years, please include clinic name and phone numbers for these offices:
How did you hear about us?

Therapies and Diets
Please list ALL medications (not just those used for skin or allergy issues) your pet is currently taking (include supplements, topicals, etc.) and are these meds currently being given. Please be specific and include dosage and frequency:
Please list medications previously used for the current dermatologic problem. Please note if they were helpful or not:
Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease? (0 = no itch, 10 = constant / severe scratching)
Did any medications help the problem for itching? If so, which ones?
Other than skin disease, does your pet have any diagnosed medical problems?
Please list all other diagnosed medical conditions and all the medications being taken for these conditions.
Does your pet have any history of adverse reactions to medications?
If yes, please explain:
What diet do you feed your pet currently? List brand and type if possible.
How many bowel movements does your pet have per day?
Have any diets been tried as treatment?
If yes, which ones and how long was it given?

Pet Household and Environment
How often do you usually bathe your pet?
What shampoo do you use?
How often do you clean your pet's ears and what do you use?
What flea, tick, and heartworm prevention products are you using on your pet?
How frequently do you administer (or give) flea prevention products to your pet?
Do any other pets or humans in the household have skin problems?
If yes, please explain:
What other pets are in the household?
Are there any other symptoms that your pet has that have not been described above, or is there anything else you think might be contributing to your pet's skin or ear disease?
Has your pet lived or traveled outside the current geographic area? If so, where else?
Authorization and Payment Policy
All fees are due at the time services are provided. Any medications, antigens, or other medical supplies mailed to you will be billed separately and in addition to appointment charges. We accept cash, Mastercard, Visa, Discover, American Express, and Care Credit. We also participate with certain pet insurance plans. Contact us for more details.

Medical files, case information and/or photos may be used in teaching, forms, continuing education, veterinary literature, website, social media and the like. I authorize the release of case/patient information for such purposes; client confidentiality (client names and personal information) will be maintained.
Client Acknowledgement
Signature
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New Client Patient Form