New Client Forms in Lacey, WA | Dermatology Clinic for Animals

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- Office Gallery
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Services
Resources
Contact
How Did We Do?

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New Client Forms

**This form may take up to 20 minutes to complete.**

Owner #1*

Owner #1 Phone Number*

Please indicate*

Cell

Home

Work

Can we send you text messages?*

Yes

No

Owner #2

Owner #2 Phone Number

Please indicate

Cell

Home

Work

Can we send you text messages?

Yes

No

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

May we contact you by Email?

Yes

No

Email*

Driver's License

Employer

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. *

Name of Clinic

Location/Phone Number

Type of Practice (General or Specialty)

Current or Former?

Pet Information

Name of Pet*

Species

Dog

Cat

Breed*

Color*

Age/DOB*

Sex

Male

Female

Spayed / Neutered?

Yes

No

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?

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

If so, where?*

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

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)?

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

Please Explain*

Cough

Please Explain*

Sneeze

Please Explain*

Vomiting

Please Explain*

Diarrhea

Please Explain*

Loose stools

Please Explain*

Frequent defecation (4+/day)

Please Explain*

Increased flatulence

Please Explain*

Burping “gurgling stomach”

Please Explain*

Regurgitation

Please Explain*

Limping/arthritis

Please Explain*

Excessive drinking

Please Explain*

Excessive urination

Please Explain*

Excessive hunger

Please Explain*

Excessive panting

Please Explain*

Weight gain

Please Explain*

Weight loss

Please Explain*

Heat intolerance or “slowing down”

Please Explain*

Other, please explain

Does your pet frequent the following facilities?

Groomers

Daycare

Dog Park

Veterinary Hospital

If so, how often?*

Groomers

If so, how often?*

Daycare

If so, how often?*

Dog Park

If so, how often?*

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

Signature*

8300 Quinault Drive NE Suite A, Lacey, WA 98516
Phone: (360) 350-4756 Call Us Today!
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