VADC New Patient Forms

David Senter, DVM, DACVD

Michelle LeRoy, DVM, DACVD

Cassidy Yanes, DVM

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:

Other

Breed:

Pet's color:

Pet's Birthday (if unknown, give approximate age below)

Date

Pet's Approximate Age:

Pet's Gender:

Has your pet been spayed or neutered?

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.

Dermatologic History

How old was your pet when obtained?

Where was your pet obtained?

Briefly describe your pet's problem:

Approximate date or age when problem was FIRST noticed:

Onset:

Has the problem ever been seasonal?

If yes, when was the problem worse?

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.)

If your pet is itchy, when?

Where do you and your pet live?

Percentage of time your pet spends indoors:

Percentage of time your pet spends outdoors:

Has your pet ever been out of your home state or the United States?

If yes, where has your pet traveled?

What other pets are in the household?

Are any of the other pets affected by the problem?

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

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?

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

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?

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?

Does your pet have any other medical problems?

If yes, please describe below:

Please provide any other information that you think may be helpful.