24/7 Emergency Vet Care • Speciality Services Monday - Thursday

New Patient Form: Dermatology

If your pet has an upcoming dermatology appointment with Dr. Tina Brown, please complete the specialty form using one of the options below.

OPTION 1
Complete Online

Complete and submit the form below.

OPTION 2
Print & Complete

Bring the completed form with you.

Download PDF

OPTION 3
Complete on Arrival

If you prefer, you can complete the form when you get to our hospital.

Dermatological History

We appreciate your cooperation in providing us with the following information.

Client First Name

Client Last Name

Phone

Pet's Name

Describe your pet's skin problem.

When did the problem first appear?

Describe the problem as it first appeared.

What parts of your pet were first affected?

If no, please explain.

From where did you obtain your pet?

How long have you had your pet?

Describe the indoor environment of your pet (such as pet's bedding, where it sleeps, etc.)

Describe the outdoor environment of your pet (grasses, weeds, wooded areas, etc.)

If yes, please explain.

Which of the following does your pet do excessively (Choose all that apply).

Chew

Bite

Lick

Rub

Scratch

Other

None

All of the above are signs of itching. Please rate the level of itching on a scale of 1 to 10 (10 being severe)

If present, what are the primary areas that your pet licks, chews, rubs or scratches.

If no, what were the first signs you noticed?

If yes, please explain.

Please list any other pets.

If “yes,” please list what you use.

Frequency of application

What treatment has your pet received for the skin problem? If possible provide drug names, dosages, and duration of treatment.

Describe what response there was to this treatment.

When was it last given or applied?

Which medication was most effective at controlling your pet’s skin problem?

Please list the current medications you pet is receiving.

If “yes,” please describe.

Medications used for this problem.

If “yes,” please describe.

Describe the diet of your pet.

What heart worm preventative do you use for your pet?

Thank You!

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From Our Clients

"You were all so kind, caring and friendly from the phone call to picking him up after Briggs surgery was a great experience. I would highly recommend y’all to anyone needing your services. Thank you for being so good with Briggs and taking such good care of him! Thanks for making me feel better the whole time I was there and when when I came to pick him up!"
Tiffany E.