Dermatology New Patient Form (HVSH) Please complete the form below prior to your appointment. If you have any questions please email us at info@metro-vet.com. "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Your Pet's Name*Your Name* First Last Your Email* Has your pet had any adverse reactions to medications or drug allergies?* Yes No If yes, list medicationsWhat are your pet’s current problems? Hair loss Scratching, chewing, licking, or rubbing Red bumps, pimples, scabs Ear infections Skin infections Excessive dandruff or scaling Skin odor Nail infections or nail loss How long have these problems been present?Have there been similar symptoms in the past? Yes No Is there currently a relationship between your pet’s problem(s) and the season? Yes No If yes, which seasons? Spring Summer Fall Winter Was there a seasonal relationship in the past? Yes No If yes, which seasons?Current itch level (1 = occasional, 10 = severe/constant) 1 2 3 4 5 6 7 8 9 10 Have any treatments or medications helped, even temporarily? Yes No If yes, which medications or treatments?Do you have other pets? Yes No List other petsDo your other pets have skin problems? Yes No Does Not Apply If yes, describe their problemsHow many hours per day is your pet outdoors?What flea products do you use and when was the last dose?Has anyone in your household had skin problems since your pet’s issues began? Yes No If yes, please describeWhat oral or injectable medications is your pet currently receiving?What topical treatments (shampoos, sprays, creams) are currently used?What ear medications or cleansers are currently used?Has your pet ever been on a prescription food elimination diet? Yes No If yes, which food was used and for how long?Were treats, table foods, or flavored medications given during the diet? Yes No What food is your pet currently eating?Does your pet have other medical or surgical issues unrelated to skin? Yes No If yes, please describe
