HISTORY FORM

Important Information About Visiting Us

1.       High demand for our services has resulted in prolonged wait times for appointments to see our doctors. They are doing the best they can, but there are very few dermatologists currently taking appointments in Maryland.

2.       Due to clients failing to appear for scheduled appointments and taking spots from other deserving patients, we are asking for credit card numbers to hold your appointment. If cancellations are not made at least 24 hours prior to a scheduled appointment time, the consult fee will be charged in full.

3.       In the hopes of helping patients who are unable to get in to see us in a timely manner, our doctors are doing telemedicine consults with your regular general practice vets. They can review case histories, lab work, and pictures of patients in order to advise the regular vet on diagnostic and treatment plans. Ask your vet to contact us to arrange such consults.

History Form - Fill Out Before First Visit

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Pet's Name *

Sex *

Breed *

Age *

Color *

Select One *

Chief Complaint(s) *

Age when problem first noted *

Onset *

Seasonal Influence? *

If yes, which season? *

Where on your pet did the problem begin? *

What did it look like then? *

Does your pet itch? *

When does your pet itch? *

What areas of your pet's body are most affected? *

Where did you obtain your pet? *

Is there exposure to other animals? *

Do other animals or people in proximity have skin problems? If yes, describe *

Describe pet's indoor environment (i.e. carpet, tile, hardwood) *

Describe your pet's outdoor environment (i.e. grass, fenced yard, farm) *

Approximately what percent does your pet spend indoors vs outdoors? *

Where does your pet sleep? *

Groomed regularly? How often? *

What diagnostic tests has your regular vet performed? *

What topical treatments have been used? *

What oral treatments have been used? *

When did you last see fleas on your pet? *

What treatments have been successful? *

Currently using flea prevention? *

If yes to flea prevention, what brand? *

Is your pet on heartworm prevention? *

If yes to heartworm prevention, what brand? *

Briefly describe your pet's diet and how long they've been on that diet *

Does your pet have a history of vomiting, diarrhea, or soft stools? *

List all medications your pet is currently using *

Are there any other facts you think might be helpful? *

Submit