Dermatology Intake Form

Today's Date *

Name *

First

Last

Email *

What is the primary reason for your visit? *

What is the approximate date that these issues started? *

Are there times when the symptoms are less severe? Does this condition seem seasonal? *

What was the first indication of the problem (for example: hair loss, skin lesions or a rash, itching)? *

What number would you score your pet’s itchiness? *

Are any other pets in your house affected? *

Have you used any treatments in the past? *

Which of those previous treatments were helpful? *

Is your pet on any flea/tick prevention? *

What shampoo and ear cleanser do you use, if any? *

Have you tried prescription diets? *

How is your pet’s behavior at the veterinary office? With ear exams? *

Current medications? Please list dose and frequency *

Any other comments?

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Fax: (970) 482-6775
Email: raintree@raintreepets.com

Mon – Fri: 7:30 am to 5:00 pm
Sat – Sun: Closed

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