Recheck Form

Phone Number *

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Do You Consent To Your Pet's Consultation Being Audio Recorded For Medical Record-Keeping Purposes? *

Recordings are confidential and used only for clinical documentation and internal purposes

YES

NO

Is Your Pet Focusing On Any Of The Following Issues?

Select Those That Apply

ITCHING

LICKING

CHEWING

SCRATCHING

RUBBING

Any Skin Lesions? *

YES

NO

Is Your Pet On Any Flea/Tick/Heartworm Prevention *

YES

NO

Which Season Is Your Pet Most Affected? *

Spring

Summer

Autumn

Winter

Year Round

Is There Another Cat Or Dog In The House? *

Select all the apply

Cat

Dog

Both

None

Do you have files (pictures or documents) to upload? *

Yes

No