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Dermatology New Patient Form
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
URL
This 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 medications
What 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 pets
Do your other pets have skin problems?
Yes
No
Does Not Apply
If yes, describe their problems
How 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 describe
What 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
