VADC New Patient Forms

David Senter, DVM, DACVD

Michelle LeRoy, DVM, DACVD

Board Certified Dermatologist | Diplomate American College of Veterinary Dermatology
Client Information
Name

First NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:

Area CodePhone Number
Home Phone Number:

Area CodePhone Number
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Current Employer:
Pet Information
Pet's Name:
Species:

DogCatOther
Breed:
Pet's color:
Pet's Birthday (if unknown, give approximate age below)

MonthDayYear
Date
Pet's Approximate Age:
Pet's Gender:

MaleFemale
Has your pet been spayed or neutered?

YesNo
General Medical Information
MEDICAL ALERT INFORMATION
Please note any pre-existing conditions for which your pet has been, or is currently being treated, as well as any drug allergies, prior surgical complications etc. that may affect the way we treat your pet
Name of Family Veterinarian and Clinic/Hospital:
How did you hear about the Veterinary Allergy and Dermatology Clinic (VADC)?
I hereby authorize the Doctor on duty and his/her assistants to administer treatment as is considered therapeutically and/or diagnostically necessary on the basis of their findings. Results are not guaranteed. I hereby certify that I have read and fully understand the above authorization. I assume full responsibility for all charges, consent to the release of medical information, and I authorize direct payment to Veterinary Allergy & Dermatology Clinic, LLC. I understand that all professional fees are due at the time services are rendered.

YesNo
Dermatologic History
How old was your pet when obtained?
Where was your pet obtained?

BreederPet ShopPrivateHumane Society/ShelterStrayOther
Briefly describe your pet's problem:
Approximate date or age when problem was FIRST noticed:
Onset:

SuddenGradual
Has the problem ever been seasonal?

YesNo
If yes, when was the problem worse?

SpringSummerFallWinter
Where on your pet's body did the problem FIRST begin?
What did the problem look like when it FIRST began?
How has the problem changed or spread?
Is your pet itchy (itch = scratching, biting, chewing, licking, rubbing, etc.)

YesNo
If your pet is itchy, when?

ConstantlySporadicallyDayNight
Where do you and your pet live?

CitySuburbsRural
Percentage of time your pet spends indoors:

0%20%40%60%80%100%
Percentage of time your pet spends outdoors:

0%20%40%60%80%100%
Has your pet ever been out of your home state or the United States?

YesNo
If yes, where has your pet traveled?
What other pets are in the household?
Are any of the other pets affected by the problem?

YesNo
Do any human members of the household have skin problems or rash?

YesNo
If yes, please describe:
What kind of food(s) does your pet eat (brand and type--dry or canned)?
Have there been any changes to your pet's diet?

YesNo
If yes, was the pet's skin affected by the dietary change?

YesNo
If yes, please describe how dietary change affected your pet's skin:
How frequently is your pet bathed?
How long ago was the last bath given?
Please provide names of shampoos/conditioners used:
Are you using any flea medications on your pet?

YesNo
If yes, what kind and how often do you give/apply?
When was the last time you saw fleas on any of your pets?
What medications has your pet received for his/her skin problem in the past?
Which of these medications were helpful?
What medications is your pet currently receiving (including any eye and ear medications)?
If applicable, what is your pet's heartworm preventative?
Does your pet have exposure to any of the following?

CatsDogsBirds (in the home)Moldy areasFeathers (pillows, etc.)Tobacco smokeCorn fieldsWoolAlfalfa fieldsGrass pastures
Does your pet have any other medical problems?

YesNo
If yes, please describe below:
Please provide any other information that you think may be helpful.
Should be Empty: