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 Information

Veterinary Information

How did you hear about us?(Required)

Patient Information

MM slash DD slash YYYY
Please 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.
Please 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?
Please list product name and how often used.
Please list product name and how often used.
Please tell us what brand(s) and flavor(s) of food your pet eats.
Do you flush the ears?
Do you bathe your pet?
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)

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