*

First Name

Last Name

Phone / Cellphone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Pet's Sex

Male

Female

Spay / Neuter

Yes

No

What is your pet’s main skin or ear issue?
 *

Itching


Redness


Hair loss


Odor

Ear problems

Dandruff

Rash

Other

Has it spread?

Yes

No

Has your pet been treated before for this issue?

Yes

No

Does it get worse during certain seasons or times of day?


Spring

Summer

Fall

Winter

Morning

Night

Indoors

Outdoors

Other

Is your pet doing any of the following?

Scratching

Licking

Chewing

Scooting

Rubbing ears or face

Other

Has your pet had any of the following recently?


Vomiting

Diarrhea

Coughing

Sneezing

Ear shaking

Other

Have you tried any special diets for skin issues?

Yes

No

Any previous or current illnesses?

Yes

No

Time spent indoors vs outdoors:

Mostly indoors

Mostly outdoors

Mixed

Grooming/bathing schedule:


At home

Professional groomer

Not regularly groomed

Has your pet traveled or stayed somewhere recently (boarding, pet-sitter, etc.)?

Yes

No

Are other pets in the home?

Yes

No

Do any humans in the household have skin issues?

We respect your privacy, and you are not required to answer this question if you’re not comfortable.

Yes

No

Does your pet currently have fleas?

Yes

No

Flea control used on pet:

Yes

No

Flea control used in the home or yard:

Inside the house

Outside (yard/patio)

Year-round

Seasonal

Non