New Client Form - Dog Your Name * First Name Last Name Pet's Name * Contact number * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Clinic location you'd like to attend Patient's age or date of birth What breed is your pet? What is your pet's gender - note if desexed How long have you owned this pet? Do you have pet insurance - if so with which company? What is your pet's insurance policy number (if applicable)? What is the name of your regular vet clinic? * Have you taken your pet to any other vet clinic? What is your main concern about your pet? * What age was the condition first noticed/how long has your pet had this issue? Have there ever been any previous skin or ear problems? Do you know of any relatives of this pet that have skin or ear problems? Percentage of time your pet spends indoors versus outdoors? Do you have any other pets? If yes which species? If you have any other pets are they also affected? Do you or anyone else in your household have skin problems? Do you use flea control on your pet? If so which product and how often do you apply it? Do you use environmental flea control in your house or garden? If yes how frequently? What type of bedding does your pet mostly sleep on eg wool, polyester, on your bed? Do you take your pet to a groomer? If yes how ofen and what does the groomer do? Have you observed any of the following symptoms? * Itching Sores Redness Dandruff Increased appetite Tiredness Weight loss Hives Heat Scabs Ear infections Diarrhoea Hair loss Odour Increased thirst Weight gain Lethargy Coughing Sneezing Runny eyes/ocular discharge Vomiting Loss of appetite Increased urination Lameness Other How itchy is your pet on a scale of 0 - 10? * Where did the issue start? Muzzle Eyes Ears Neck Back Sides of chest Rump Tail Tummy Inner thighs Underarm area Front legs Front paws Back legs Back paws Bottom Groin Other Has it spread, if yes, to where? Ear infections (if applicable) Have any of the following been observed? Ear discharge Head shaking Scratching the ear Rubbing the ear Head tilt Haematoma Loss of balance Abnormal eye movement Odour from the ear Other Do you know of any releatives of this pet that have ear problems? If the skin/ear problems have been present for some time, which season(s) are they worse? Are the symptoms present all year round? Select one option Yes No What (if anything) causes a worsening of the symtoms? What helps the symptoms? Is your pet receiving any other medication(s)? Please list any vitamins or food supplements your pet is taking (if any) How often do you bathe your pet and which shampoo do you use? What is your pet's current diet including treats? How long has your pet been on this diet? How many bowel movements does your pet have each day? What is the consistency of your pet's stools: normal, soft, watery, very firm, any other variety? Has your pet received treatment for stomach or intestinal problems? If yes please expand Any additional comments? Do you consent to us posting images of your pet and using case information on our social media pages and website? * Yes No Please acknowledge that e reserve the right to amend our prices when necessary. * Yes Please acknowledge that if you schedule an appointment but then fail to attend the confirmed appointment you will be charged a cancellation fee equvalent to the price of the consultation fee. The same fee applies to cancellations made less than 48 hours prior to the appointment. * Yes Thank you!We’ll be in touch if we require any further information.We look forward to meeting you soon! Please complete this questionnaire prior to your initial consultation.
