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Dermatology Re-Check 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

Your Pet's Name*

Your Name*

First Last

Your Email*

Consent & Billing

I understand there is an EXAM FEE associated with this visit – please initial*

Cytology (if needed): Skin cytology (1) $45, (2) $67, (3) $79 | Ear cytology (1) $65

If needed, are cytologies authorized?*

Yes, authorized

No – discuss first

Health Updates Since Last Visit

Changes in general health since we last saw you?*

Medications (Oral & Topical)

List all current medications (add rows as needed)*

Medication

Dose (mg)

Frequency

Last Given (date/time)

Effective (Y/N)

Include oral and topical meds. Provide dose in mg, how often you give it, when the last dose was given, and whether it seems effective.

Have you missed any doses? If so, which and when?

Have you run out of any medications? If so, which and when?

Itch & Lesions

Overall itch level (0–10)*

Please enter a number from 0 to 10.

0 = none, 10 = severe constant itching

Focal spot(s) (areas most affected)

Diet & Allergy Therapy

Strict food trial?*

Yes

No

If on a food trial, how long?

Food trial effective?

Yes

No

Allergy vaccine (immunotherapy)?*

Yes

No

If on allergy vaccine: dose

If on allergy vaccine: how often

If on allergy vaccine: last given

If itch increases with vaccine, when does it occur?

Parasite Prevention

Is your pet on flea and tick prevention?*

Yes

No

Which product?

In An Emergency

Phone MVA: 610-666-1050
Phone Hickory: 610-839-8538
Phone MVUCS: 610-616-8827

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Metropolitan Veterinary Associates
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Hickory Veterinary and Specialty Hospital
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