Patient Info
Where was your pet obtained? —Please choose an option— Breeder Pet Shop Private Human Society Stray Other
Date problem was first noticed
Onset? Sudden Gradual
Has the problem ever been seasonal? Yes No
Is the problem still seasonal?? Yes No
Where on your pet's body did the problem first begin?
What did the problem look like when it first began?
how has the problem changed or spread?
Where do you and your pet live? —Please choose an option— City Suburbs Rural Mountains
Percentage of time your pet spends:
Describes your pet’s indoor environment
Describes your pet’s outdoor environment
If a dog, does he/she go to doggie day care? Yes No
If your pet spends much time in the mountains, please estimate number of visit and amount of time spent in the mountains per visit
Has your pet ever been out of your home state or the United States?Yes No
What other pets are in the household?
Are any of the other pets affected by the problem?Yes No
Do any human members of the household have skin problems?Yes No
Does your pet have exposure to any of the followings? cats dogs horses (within 1 mile) cattle (within 1 mile) tobacco smoke perfumes sheep (within 1 mile) birds (in the home) cement jasmine plants potpourri feathers wool scented litter scented candles pine scented cleaner's plastic dishes
Are carpet deodorizers used in the home? Yes No
Describe your pet’s diet (Be as specific as possible.....brand & type (dry, semi-moist, canned) & duration fed, in the following foods: Commercial Pet Food Table Foods Treats Supplements Other Foods
Have there been any changes in your pet’s diet? Yes No
Describe the affect to the skin
FINANCIAL POLICY
Payment is due as services are rendered. The balance will be due upon discharge from the hospital. You may pay by cash, Care Credit, or accepted credit cards.
In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance.
