Please fill out the below information to the best of your ability prior to your pet's appointment. |
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Pet's Name (required)
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E-Mail Address :
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What is the best phone number to reach you on when you are here with your pet for the appointment? (required)
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Is anyone in your household showing COVID symptoms, recently tested positive for COVID, been exposed to someone with COVID, or on Department of Health Quarantine? (required)
Yes
No
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To make it easier for us to see when you arrive, please tell us the model of your car and color
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How has your pet been since the previous visit? (required)
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If not doing well, when did the symptoms worsen?
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Where on the skin are the most affected areas?
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Are there any particular areas or lesions that you want the doctor to check or any other relevant updates you would like the doctor to know about?
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What is the overall level of improvement your pet has shown since starting treatment here?
Mild improvement (approximately 25% better)
Moderate improvement (approximately 25-50% better)
Significant improvement (approximately 50-75% better)
So much improvement that my pet only has minimal to no symptoms
No improvement/change in symptoms
Symptoms have gotten worse
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Please rate your pet's itch level on a scale of 1 to 10 (1 = minimal, 10 = obsessive/constant)
1
2
3
4
5
6
7
8
9
10
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How often are you bathing your pet?
At least twice weekly
Weekly
Every couple of weeks
As needed
Never
Only when groomed
I can't even keep up with bathing myself never mind my pet
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How much allergy vaccine are you giving to your pet and how often are you giving it?
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Do you notice any trends with your pet's allergy vaccine (more itchy before being due for the injection or more itchy after the injection)? If so, please describe
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Are you giving your pet any antihistamines such as generic or brandname Zyrtec, Clairitin, Benadryl, other? Please include the total milligrams and how often
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Please list any other medications you are currently giving your pet. Please include the total milligrams and how often
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Do you need any refills of medications while you are here including allergy vaccine? Please include the desired quantity.
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What is the name of your pet's primary care veterinarian and/or veterinary office?
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