Existing Patient update

Please fill out this form before your recheck appointment.

Owner name

Pet name

How has your pet been doing since your last visit?

How itchy is your pet (10 = horribly itchy)

What problem areas do you notice?

Do you have non-dermatologic issues to discuss?

Please list current medications, including injections:

For recently completed medications, please list names and when discontinued:

Shampoo name

Shampoo frequency

Ear Medications

Ear medication frequency

Ointments/creams

Ointments/creams location and frequency

Mousses/wipes

Mousses/wipes location and frequency

Please outline your pet's current diet, including supplements

Is your pet up to date on flea/tick prevention? If so, which product?

Do you need any medication refills today? If so, which product and quantity desired?

Have you visited another veterinarian since your last visit here? Please let us know if there are relevant records that we should request.