Initial Appointment Form Owner Information LAST NAME * FIRST NAME * MAIN PHONE NUMBER * (###) ### #### SECONDARY PHONE NUMBER (###) ### #### ADDRESS LINE 1 * ADDRESS LINE 2 CITY/TOWN * PROVINCE * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon POSTAL CODE * EMAIL * SECOND OWNER INFORMATION LAST NAME * FIRST NAME * MAIN PHONE NUMBER * (###) ### #### SECONDARY PHONE NUMBER (###) ### #### EMAIL * DO YOU AGREE TO RECEIVE PET'S CONFIDENTIAL INFORMATION VIA EMAIL? * Includes, summary reports, bloodwork, test results, etc. YES NO CAN EITHER OWNER GIVE CONSENT? * YES NO IF NO, PLEASE EXPLAIN DO YOU CONSENT TO PHOTOGRAPHS OF YOUR PET TO BE USED FOR TEACHING OR RESEARCH PURPOSES? * YES NO CONSENT FOR YOUR PET'S CONSULTATION BEING AUDIO RECORDED FOR MEDICAL RECORD-KEEPING PURPOSE? * Recordings are confidential and used only for clinical documentation and internal purposes YES NO PLEASE NOTE: WE REQUIRE THAT THE PRIMARY CAREGIVER WHO HAS AUTHORITY TO GIVE CONSENT BE AVAILABLE TO SPEAK WITH DURING THE CONSULTATION Patient Information PATIENT'S NAME * DATE OF BIRTH OR AGE * SPECIES * BREED * SEX * Male Male Neutered Female Female Spayed IS YOU PET INDOOR ONLY OR DO THEY HAVE OUTDOOR ACCESS? * DOES YOUR PET REQUIRE A MUZZLE OR SEDATION TO BE EXAMINED? * DO YOU HAVE ANY OTHER ANIMALS AT HOME? * HISTORY WHAT SKIN/EAR ISSUES IS YOUR PET BEING REFFERED FOR? * WHAT AGE DID THE SKIN ISSUES FIRST START? * WHAT BODY PARTS ARE MOST AFFECTED? * IS YOUR PET LICKING, CHEWING, RUBBING, SCRATCHING? * YES NO WHEN? CONSTANTLY SPORADIC NIGHT ONLY ITCH LEVEL * 0 = Not Itchy, 1-2 = Very Mild Itch, 3-4 = Mild Itch (more frequent), 5-6 = Moderate Itch (regular episodes), 7-8 = Severe Itch (prolonged), 9-10 = Extremely Itchy (continuous, unable to rest). DO THE SIGNS LAST ALL YEAR OR IS THERE A TIME OF YEAR THAT IS BETTER OR WORSE? * ARE ANY OF THE OTHER ANIMALS OR HUMANS IN THE HOUSEHOLD AFFECTED? * CURRENT MEDICATIONS IS YOUR PET CURRENTLY TAKING ANY MEDICATIONS? * YES NO PLEASE LIST (INCLUDE DOSE AND FREQUENCY) IS YOUR PET CURRENTLY RECEIVING ANY SUPPLEMENTS? * YES NO PLEASE LIST ARE YOU CURRENTLY DOING ANY TOPICAL THERAPIES * BATHING, EAR CLEANERS, WIPES, MOUSSES YES NO PLEASE LIST PLEASE LIST (INCLUDE PRODUCT AND FREQUENCY) FLEA CONTROL IS YOUR PET RECEIVING FLEA/TICK/HEARTWORM PREVENTATIVES? * YES NO WHAT ARE YOU GIVING? WHEN WAS THE LAST DOSE GIVEN? DO YOU TYPICALLY GIVE IT YEAR-ROUND OR ONLY FOR PART OF THE YEAR? IF YOU HAVE OTHER PETS AT HOME, ARE THEY ALSO ON FLEA CONTRO? * YES NO N/A DIET WHAT DIET ARE YOU CURRENTLY FEEDING? * WHAT TREATS ARE YOU CURRENTLY GIVING * IF YOUR PET IS RECEIVING ORAL MEDICATIONS, HOW ARE YOU ADMINISTERING THEM? I.E., HIDE IN PEANUT BUTTER, CHEESE, OTHER WHAT PROTEIN SOURCES HAS YOU PET EATEN IN THE PAST? * I.E., CHICKEN, BEEF, LAMB, FIST, ETC HAVE YOU EVER PERFORMED A STRICT DIET TRIAL OR ELIMINATION DIET WITH A PRESCRIPTION DIET? IF YES, WHICH PRESCRIPTION DIETS HAVE BEEN FED AND FOR HOW LONG? HOW MANY BOWEL MOVEMENTS DOES YOUR PET TYPICALLY HAVE IN A DAY? * WHAT IS THE CONSISTENCY OF THEIR BOWEL MOVEMENTS? * DIARRHEA, SOFT, NORMAL, HARD, CONSTIPATED, ETC DOES YOUR PET HAVE ANY GASTROINTESTINAL ISSUES? I.E., VOMITING, GAS, ANAL SAC ISSUES, WEIGHT LOSS, ETC IS THERE ANY OTHER INFORMATION THAT YOU WOULD LIKE TO ADD? Thank you! Your submission has been received.Please remember to bring any previous medications—including pills, ointments, ear cleaners, and shampoos (even if the containers are empty)—to your consultation.Photos of medication labels and ingredient lists are perfectly fine if you prefer not to bring the items.Also include treat and food ingredient labels or pictures of those as well.
