New Patient Form: Dermatology

If your pet has an upcoming Dermatology appointment with Dr. Tina Brown, please complete the specialty form using one of the options below.

OPTION 1
Complete Online

Complete and submit the form below.

OPTION 2
Print & Complete

Bring the completed form with you.

Download PDF

OPTION 3
Complete on Arrival

If you prefer, you can complete the form when you get to our hospital.

Dermatological History

We appreciate your cooperation in providing us with the following information.

Client Name *

Patient Name *

Describe your pet's skin problem. *

When did the problem first appear? *

What the onset gradual or sudden? *

Describe the problem as it first appeared. *

What parts of your pet were first affected? *

Has your pet always lived in this part of the country? *

If no, please explain.

From where did you obtain your pet? *

How long have you had your pet? *

Where does your pet spend most of its days? *

Describe the indoor environment of your pet (such as pet's bedding, where it sleeps, etc.) *

Describe the outdoor environment of your pet (grasses, weeds, wooded areas, etc.) *

Which of the following best fits your pet's skin problem? *

Is there a relationship between the severity of your pet's skin condition and the season of the year? *

If yes, please explain.

Which of the following does your pet do excessively (Choose all that apply). *

Chew

Bite

Lick

Rub

Scratch

Other

None

All of the above are signs of itching. Please rate the level of itching on a scale of 1 to 10 (10 being severe)

If present, what are the primary areas that your pet licks, chews, rubs or scratches.

Was itching the first sign of your pet's skin disease that you noticed. *

If no, what were the first signs you noticed?

Has your pet ever had ear problems? *

If yes, please explain.

From Happy Pet Owners

“They saved my dog’s life three years ago with a spinal surgery. He’s still doing great!”
Kevin C.

New Patient Form: Dermatology

OPTION 1Complete Online

OPTION 2Print & Complete

OPTION 3Complete on Arrival

Dermatological History

From Happy Pet Owners

OPTION 1
Complete Online

OPTION 2
Print & Complete

OPTION 3
Complete on Arrival