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.
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Communication Notice:

We send appointment reminders by text message and email. Financial statements are sent by email to the address you provide on this form. By signing below, you consent to receive email, text, and phone calls from Golden Gate Veterinary Specialists.
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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?*

Pet Diet and Previous Therapies
Please list ALL medications your pet is currently taking (include supplements, topicals, etc.) and are these meds currently being given: *
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?*

YesNo
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?*

YesNo
If yes, please explain:*
What diet do you feed your pet currently? *
How many bowel movements does your pet have per day?*
Have any diets been tried as treatment?*

YesNo
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?*
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?*

YesNo
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?*
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*

* I agree to the Golden Gate Veterinary Specialists policies stated above. I understand that no guarantee can be made as to the results obtained from medical treatment and I assume financial responsibility for all charges incurred by my pet.* I agree to provide a minimum of 24 or 48 hours’ notice depending on each practice’s local policy (exception-by noon Friday for a Monday appointment) to cancel or reschedule an appointment. In some cases, a rebooking fee may be charged if insufficient notice has been provided.* I authorize the Golden Gate Veterinary Specialists, its employees, agents, or representatives to contact me regarding patient information, patient refills and treatment updates. I understand that this authorization may also include 3rd party vendors such as our online pharmacy, and automated reminder services associated with the Golden Gate Veterinary Specialists.
Signature*

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Today's Date*

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New Client Patient Form

Client Information

Communication Notice:

Pet Information

Pet Condition

Pet Diet and Previous Therapies

Pet Household and Environment

Authorization and Payment Policy