New Patient Form
*indicates required fields (**This form may take up to 20 minutes to complete.**)
Owner Information
Owner #1 Name
First Name
Last Name
Owner #1 Phone Number
Please enter a valid phone number.
Please indicate
Cell
Home
Work
Can we send you text messages?
Yes
No
Owner #2 Name
First Name
Last Name
Owner #2 Phone Number
Please enter a valid phone number.
Please indicate
Cell
Home
Work
Can we send you text messages?
Yes
No
REQUIRED FIELD: Address - NO P.O. BOXES - this must be a physical address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
May we contact you by Email?
Yes
No
Email
example@example.com
Employer
REQUIRED FIELD: BEHAVIORAL HISTORY: Has your pet ever bitten a person or veterinary staff member at a veterinary visit?
*
Yes
No
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?
*
Yes
No
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)
*
Yes
No
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?
*
Yes
No
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
City
State / Province
Postal / Zip Code
Pet Information
Pet Information
*
Patient History
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?
Seasonal
Continuous
If the problem was initially seasonal, which season(s)?
Winter
Spring
Summer
Fall
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)
Normal skin, just itchy
Hair loss
Rash
Pimples
Redness
Where did it start? (Please check)
Nose
Eyes
Ears
Neck
Back
Rump
Tail
Front paws
Back legs
Back paws
Chest
Abdomen
Groin
Elsewhere
Has it spread?
Yes
No
If so, where?
Does your pet scratch, rub, chew, lick, or bite the following? (Please check a box)
Nose
Muzzle
Eyes
Ears
Neck
Back
Rump
Tail
Armpits
Front legs
Back legs
Thighs
Back paws
Front paws
Chest
Abdomen
Groin
If so, where?
Was the itching the first thing noticed?
Yes
No
Percent of time pet is confined indoors (%)?
Percent of time pet is Outdoors (%)?
What is your primary indoor flooring surface?
Carpet
Tile/linoleum
Wood
Wool (carpeting, rugs, dog beds, blankets, etc.)
Where/when are symptoms the worst?
Indoors
Outdoors
Nights
Mornings
If a female, are or were there normal heat cycles?
Yes
No
If a male, does he have normal interest in females?
Yes
No
Do any relatives of your pet have any skin problems that you are aware of?
Yes
No
If yes, explain:
Do you use flea control?
Yes
No
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?
Yes
No
Frequency?
Do you use insecticides in your home?
Is your pet exposed to tobacco smoke?
Yes
No
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
Other
Apoquel
It was helpful
It was not helpful
Cytopoint
It was helpful
It was not helpful
Antihistamines
It was helpful
It was not helpful
Steroid pills
It was helpful
It was not helpful
Steroid shots
It was helpful
It was not helpful
Antibiotics
It was helpful
It was not helpful
Antifungal
It was helpful
It was not helpful
If other, please list
Other
It was helpful
It was not helpful
Did any of the medications above help the problem?
Yes
No
If yes, which ones helped?
Is your pet currently on any other medications, vitamins, or food supplements?
Yes
No
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?
Runny eyes
Cough
Sneeze
Vomiting
Diarrhea
Loose stools
Frequent defecation (4+/day)
Increased flatulence
Burping “gurgling stomach”
Regurgitation
Limping/arthritis
Excessive drinking
Excessive urination
Excessive hunger
Excessive panting
Weight gain
Weight loss
Heat intolerance or “slowing down”
Other, please explain
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)
Groomers
If so, how often at the Groomers?
Groomers
Does your pet frequent the following facilities? (Daycare)
Daycare
If so, how often at Daycare
Daycare
Does your pet frequent the following facilities? (Dog Park)
Dog Park
If so, how often at the Dog Park?
Dog Park
Does your pet frequent the following facilities? (Veterinary Hospital)
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?
Referring primary care veterinarian
Specialty veterinarian
Friends/Family
Internet Search
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Instagram
Facebook
Other - (Please Indicate)
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