Dermatology Referral Form Please fill out this form as accurately and completely as possible. This information will help us prepare for your visit so the doctor can spend as much time as possible with you and your pet.Personal InformationClient First Name(Required) Client Last Name(Required) Second Owner First Name Second Owner Last Name Address Line 1(Required) Address Line 2 City(Required) State/Province(Required) Zip/Postal Code(Required) Country Primary Phone(Required)Secondary PhoneEmail Veterinary InformationReferring Veterinary Clinic Referring Veterinarian Referring Veterinarian PhoneReferring Veterinarian FaxHow did you hear about us?(Required) Primary Care Veterinarian Emergency Veterinarian Internet Search American College of Veterinary Dermatology Website Friend Groomer Pet Sitter Other Patient InformationPet's Name(Required) Species(Required) Dog Cat Horse Other Breed(Required) Gender(Required) Neutered Male Spayed Female Intact Male Intact Female Color(Required) Date of Birth(Required) MM slash DD slash YYYY Reason For AppointmentPlease provide us with a brief description of your pet's problem. When did it start? How has the problem progressed? What areas are affected? Is your pet itchy? Etc.Current MedicationsPlease list all medications (including dosages) that your pet is currently taking.Has your pet had any adverse reactions/side effects with medications, foods, or topical products? Yes No If you answered "YES" above, please describe:Flea/tick ControlPlease list product name and how often used. Heartworm PreventionPlease list product name and how often used. Pet's Current DietPlease tell us what brand(s) and flavor(s) of food your pet eats. What treats do you give? Are there any other medical or behavioral problems we should know about?Do you flush the ears? Yes No If so, how often and what do you use? Do you bathe your pet? Yes No If so, how often and what do you use? Do you give Animal Dermatology & Allergy permission to take photos of your pet and use these images for the purposes of medical records, continuing education, teaching, and awareness, including educational lecture presentations and social media?(Required) YES, I give permission NO, do not take photos of my pet I'm not sure- let's talk more at my pet's appointment Δ
