Enrollment and Terms Agreement for Veterinarians Please enable JavaScript in your browser to complete this form.OWNER INFORMATIONOwner's Name: *FirstMiddleLastCo-owner/Spouse's Name:FirstMiddleLastHome Phone:Work Phone:Cell Phone:Other Phone (Co-Owner/Spouse Work or Cell):WorkCellOtherBest Phone Number: *Best Time to Call:Email Address: *Fax Number:Mailing Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCheck if Street Address is same as Mailing AddressCheck box if Same as AboveStreet Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName of Employer:Occupation:PATIENT INFORMATIONPet's Call Name: *Age/DOB:Breed:Species:CanineFelineOtherSpecies (if Other):Color:Sex:Male, IntactMale, NeuteredFemale, IntactFemale, SpayedREFERRING VETERINARIANName:FirstLastHospital Name:City:State:Phone:PATIENT HISTORYCURRENT MEDICAL HISTORYPlease describe your pet's current skin problem (symptoms) in your own words: *How old was your pet when obtained? *At what age was the skin or ear problem first noticed? *How quickly did the skin or ear problem arise? *Sudden GradualContinualIntermittentHas the problem ever been seasonal? *NoYesIf yes, which season? *What area of the body did the problem begin? *Has the problem changed or spread? *Does your pet scratch, chew, or lick themselves? *NoYesIf yes, which body area? (Please list the most affected area) *When do they itch/scratch? *ConstantSporadicNightIs there hair loss? *YesNoIf yes, give distribution. *Are there changes in color of the hair? *YesNoIf yes, describe:Are there changes in the color of the skin? *YesNoIf yes, describe:What other pets are in the household?Do they have any skin problems? If so please describe.Do any members of the household have skin problems?If yes, please describe:Do any members of the household smoke?What commercial pet food do you feed your pet? * Include brand, type, dry, moist, duration fed, treats, any charges, etc:Do you feed your pet table food? * Include brand, type, dry, moist, duration fed, treats, any charges, etc:Do you feed your pet treats? * Include brand, type, dry, moist, duration fed, treats, any charges, etc:Do you give your pet supplements? * Include brand, type, dry, moist, duration fed, treats, any charges, etc:Do you give your pet heartworm prevention? * Include brand, type, dry, moist, duration fed, treats, any charges, etc:How do you give medication?Describe animal's indoor environment, time spent inside (%): *Describe animal's outdoor environment, time spent outside (%): *Do you have a fenced in yard? *YesNoDo you live in the: *CitySuburbsRuralWhat is the age of your home? *Are carpet deodorizers used in the home? *YesNoDo you live in an: *ApartmentHomeIs there a crawl space under your home? *YesNoDoes your pet go to doggie day care? *Does your pet ever have fleas or ticks? *When was the last time you found a flea or tick on your pet? *What is being used to prevent fleas (also prevents lice, scabies) and how often? *For your petWhat is being used to prevent fleas (also prevents lice, scabies) and how often? *All other cat/dogs in your homeWhat topical treatments have been used? Success? *What medications has your pet received for his/her skin problem in the past? Which ones helped? *What medications is your pet currently receiving? (Include any ear, eye, herbal medications, as well as frequency and dosage) *Are you able to administer medication to your pet? (tablets, capsules, liquid) *YesNoWhen did your pet last receive treatment for this issue, please describe what treatment: *Does your pet have any other medical problems? *YesNoIf yes, please describe (disease, treatments, results):Does your pet have any other symptoms you feel are abnormal? *YesNoIf yes, describe:Has your pet ever had a seizure? *YesNoIf yes, describe: Are you able to bathe your pet? If so, how often and for how long (minutes)?Do you, or anyone in your household feed feral or stray cats, dogs, or wildlife around your home? *YesNoDo you have birdfeeders in / around your yard? *YesNoAre there any other facts you feel might be helpful?PAST MEDICAL HISTORYIs your pet aggressive to people or other pets? *NoYesIs your pet up to date on vaccines? *NoYesIf no, explain:PLEASE FILL IN THE BOXES BELOW:Method(s) of Payment:CashCheckVisaMastercardDiscoverAmerican ExpressCare CreditI am financially responsible for all professional fees related to the above-mentioned pet by the Institute of Veterinary Specialists. I understand that payment is due at the time of service. By signing this form, I attest that I have read and will comply with these terms.NameSubmit
