Client Information and History Form

Dear valued clients: This form is for new patients with scheduled appointments only. BEFORE completing this form please call our office to set an appointment first. Submitting this form does not guarantee an appointment. Your cooperation and assistance is greatly appreciated. — ADRC Front Desk

"*" indicates required fields

Name*
Spouse/Partner
Address*
Accept text appointment reminders in the future?*
Preference for discharge letter:*
Clinic you will visit:*

Pet Data

Sex*

Referred By

How did you hear about us?*

Patient History

Areas affected if itching (scratching, chewing, licking, rubbing, biting):*
Are symptoms:*
When are symptoms more severe?*
Do any of the following occur?*

Flea Control

Do you use flea control for your pet(s)?*
Do you use environmental flea control for your yard/house?*

Pet Feeding

Allergies

Is pet allergic to any medication?*
Do you have other pets?*

If yes, do they have any skin problems?
Do any human members of the household have skin problems?*

Medications

Previous medications:*

IMPORTANT INSTRUCTIONS

Your pet has been referred to the Animal Dermatology Referral Clinic for consultation, evaluation, special testing, and/or treatment to supplement the services provided by your regular veterinarian. At the completion of the work done here, a full report will be given to you and to the referring veterinarian. Responsibility for continued health care for your pet will remain there.
Consent to Pay for Services*
Do you have an appointment scheduled?*
If NO, confirm you will CALL US FOR AN APPOINTMENT
You will not be contacted for an appointment simply by completing this form. You MUST CALL for an appointment
This field is for validation purposes and should be left unchanged.