Owner first name
Owner last name
Owner e-mail address
Address
Address Line 2 (optional)
City
State
Zip code
Cell phone number
Home phone number
Work phone number
Partner's name (optional)
Partner's phone number (optional)
Preferred phone number
Cell phone
Home phone
Work phone
Partner's phone
List of people authorized to make medical and financial decisions on behalf of your pet. Please include phone numbers if not already listed above.
List every veterinarian you have visited in the past year, as well as any others that have pertinent records. Please list veterinarian, hospital name, and phone number.
What is the name, address and phone number of your preferred human pharmacy?
How did you hear about us?
Referring veterinarian
Friend/family
Google
Google maps, Apple maps, etc.
Online other than Google
Social media
Referral from Cornell CUVS
Other
Name of referrer (if applicable) or other (if applicable)
Do you already have an appointment scheduled?
Pet name
Age of pet when acquired
Current age
Sex
Weight
Reason for visit today
Approximate date problem started
Other problems noted?
Did the condition start in one area and then spread? Please describe?
How itchy is your pet on a scale of 1-10 (10 being the worst)?
Comments on itchiness
What other pets do you have?
Do you have any other pets with skin disease?
Do you or any other person in your household have skin probems?
Do your pet's littermates or parents have skin problems? If yes, explain them
Do you have concerns regarding your pet’s energy level, appetite, urination/defecation frequency/amount/type, sneezing, vomiting/diarrhea, or any other sign unrelated to his/her skin?
Please list your pet’s current medications
Please list medications/injections your pet has taken for the skin condition
Did any medications help the problem? Which one(s)?
Please list the vitamins and food supplements your pet has been given
How often do you bathe your pet and what shampoos are used?
What other topical therapy is applied?
What is your pet's current diet, including treats?
How long has your pet been on this diet?
Does your pet have any other disease that we should be aware of?
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