arrow_back Back to Dermatology Dermatology Appointment Request Form Appointment request form InstagramThis field is for validation purposes and should be left unchanged.Who is filling out this form?(Required) Client Referring Veterinarian Are you making a referral or do you need a consult?(Required) Referral Consult Client InformationClient Name(Required) First Last Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you already have an appointment scheduled?(Required) Yes No Patient InformationPatient Name(Required)Patient IDAnimal Type Dog Cat Other Date of birth(Required)Breed(Required)Sex(Required) female intact female spayed male intact male neutered Color(Required)Veterinarian InformationVeterinarian(Required) First Last Veterinary Clinic(Required)Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Would you like your veterinarian to receive a letter summarizing your visits? Yes No Patient HistoryHow old was your pet when first obtained?(Required)Where was your pet obtained? Kennel Pet Shop Private Describe the patient's problem?(Required)How long has the problem been present?(Required)Describe the skin problem(s) as first appeared(Required)Where on the patient's body has the problem spread and how has it changed in appearance(Required)What treatments has the patient received for the skin problem? If possible, provide drug names, duration on each drug, and the effectiveness of these treatments.(Required)What medications is the patient currently receiving?(Required)Separate medications with commas If the patient has ear problems – is it affecting hearing?(Required) Yes No By what percentage has it decreased?Does the patient have any problems localizing sounds (i.e. when hears a sound, not sure where the sound came from)?(Required) Yes No Is the patient itchy?(Required) No Yes – Constantly Yes – Sporadically Yes – Nightly Where on the body is the patient itchy?Canine Itch Scale(Required)Select the average itch of your dog. Itch can express itself as scratching, biting, chewing, licking, rubbing, and nibbling. Extreme scratching/nearly uninterrupted: Whatever happens the scratching will not be discontinued, also in the treatment room (the dog has to be prevented from scratching through a collar). Severe scratching/long lasting periods: Scratching at night (if observed) and during eating, playing, going for a walk or distraction. Moderate scratching/episodes: Scratching at night (if observed) but not during eating, playing, going for a walk or other distraction. Mild scratching/slightly increased: No scratching during the night, eating, playing, going for a walk or when distracted. Very mild scratching/only occasional episodes: The dog’s itching is only slightly increased from what we think is normal. Normal dog: I don’t think itching is a problem. Feline Lick Scale(Required)Pruritus prompts cats to groom excessively and/or scratch using the hind limbs. A healthy cat, free from pruritus, spends about 1 h per day grooming (normal grooming behavior). Nonstop or nearly nonstop licking: My cat over-grooms even during the visit and/or hides constantly. Licking results in invariably hair loss and often induces skin lesions. Intense and prolonged licking: My cat wakes up and/or stops eating or playing to lick, and/or hides very often. Licking induces hair loss frequently. Moderate licking: My cat often hides and wakes up sometimes to grooming, but never stops eating or playing to do so. Licking often results in hair loss. Frequent and protracted mild licking: My cat never grooms while eating, sleeping, or playing. It occasionally hides. Licking seldom results in hair loss. Mild and episodic licking: My cat grooms more than it used to. Licking never results in hair loss. Healthy cat: Licking up to one hour a day. Feline Scratch Scale(Required)Pruritus prompts cats to groom excessively and/or scratch using the hind limbs. A healthy cat, free from pruritus, scratches around 1 min. per day. Nonstop or nearly nonstop scratching: My cat scratches even during the visit and/or hides constantly. Scratching results invariably in skin lesions. Intense and prolonged scratching: My cat wakes up and/or stops eating/playing to scratch and/or hides very often. Scratching results in skin lesions very frequently. Moderate scratching: My cat often hides and wakes up sometimes to scratch, but never stops eating or playing to do so. Scratching often results in skin lesions. Frequent and protracted mild scratching: My cat never scratches while eating, sleeping, or playing. It occasionally hides. Scratching seldom results in skin lesions. Mild and episodic scratching: My cat scratches more than it used to. Scratches never results in skin lesions. Healthy cat: Scratching up to 1 min. a day ls the problem now, or has it ever been, seasonal?(Required) No Yes – Spring Yes – Summer Yes – Fall Yes – Winter Where do you and your pet live? City Suburban Rural ls the problem worse when the patient is indoors, outdoors, or is the problem not affected by this factor?(Required)Has the patient ever been out of the client's home state or the United States?(Required)Has the patient ever been out of your home state or the United States?(Required)If the patient spends time in a different environment, is the problem better or worse?*(Required)Are there any other pets/animals in or on the property of the household?(Required) Yes No Note the number of each and whether or not they are affected by the problem.CatDogOther Add RemoveAre there any people in the household affected with skin problems?(Required)Describe the patient's diet (commercial pet food; if possible, specify brand and type – dry, semi-moist, canned – and duration fed}(Required)Have there been any changes in diet?(Required) Yes No When?Was the patient's skin problem affected by the dietary change?GroomingTimes combed or brushed per month(Required)Times bathed per year(Required)Date of last bath(Required) MM slash DD slash YYYY Shampoo used(Required)Please note all preparations used for routine groomingMedical HistoryAppetite Normal Increased Decreased Bowel Movement Normal Increased Decreased Water Consumption Normal Increased Decreased Urination Normal Increased Decreased Weight Normal Increased Decreased Does the patent have any other medical conditions? Yes No Please describeReproductive HistoryIf the patient is spayed/neutered, when?Non-spayed female: last heat cycle?Time in-between cycles?Household informationDoes anyone in the client's household work in the human medical field?(Required) Yes No Does anyone in your household work in the human medical field?(Required) Yes No Has anyone in the client's household ever been diagnosed with MRSA (methicillin-resistant Staphylococcus aureus)?(Required) Yes No Has anyone in your household ever been diagnosed with MRSA (methicillin-resistant Staphylococcus aureus)?(Required) Yes No Has the patient ever been diagnosed with a resistant staph infection?(Required) Yes No What infection?How long have they had it?Please upload images of any previous or active lesions on the patient. Drop files here or Select files Max. file size: 50 MB. Please email relevant medical records to [email protected].Acknowledgement of scheduling timeline(Required) I acknowledge the Dermatology and Otology service is booking appointments 3-4 months in advance.
