Patient Info & History Form

Patient Info & History Form

Please fill out the form below before you come in for your pet's appointment.

Thank you!

 
Pet Owner's Name: *
E-mail *
Your Pet's Information
Pet's Name: *
Age: *
Breed: *
Sex: *
Is your pet neutered? *
Your Pet's Health History:
What skin problems does your pet have? Please check All That Apply *
How old was your pet when these problems began? *
Is your pet itchy? *
On a scale of 1-10 (1: normal; 10: severely itchy), how itchy is your dog? *
What locations on the body are itchy? Check all that apply. *
Is your pet's itch present year round? *
Is your pet's itch worse during certain seasons? *
Has your pet lived in another state? *
Previous Testing
Has your pet had prior tests performed for the current problem? Check all that apply. *
Please select which lab tests have been done? *
Treatment History
Has your pet received or been prescribed any of the following? Check all that apply.
*
*
*
Shampoos: *
Sprays/wipes: *
Antihistamines
Check All That Apply *
Allergy Vaccine *
How often was it given? *
How long was the vaccine given? *
Steroids
When was last dose given *
Did it help? *
What form was given (injection or pills)? *
Side effects noted? *
Atopica *
Did it help? *
Side effects noted? *
Apoquel *
Did it help? *
Side effects noted? *
Cytopoint *
Did it help? *
Does your pet suffer from ear infections? *
Do you clean your pet's ears? *
If yes, how often do you clean them? *
Does your pet show any of the following signs at home? Check all that apply. *
Has a strict (prescription) diet trial been attempted? *
What diet(s) have been tried? Please list all: *
Is your pet on regular flea, tick and heartworm preventative? *
Please list the brands/products used: *
How often is heartworm preventative given? *
How often is flea/tick preventative given? *
Where does your pet spend most of their time? *
Do you have any other pets in the house? *
Do these animals exhibit any similar skin problems? *
Medical History
Does your pet have any of the following medical conditions? *
 

Telephone: 206.508.5500

Fax: 206.508.5520

Our building is located 2 blocks North of REI.
Free parking is available on the rooftop of the building.

Parking Directions from I-5
Take the Mercer Street exit

Turn left onto Fairview Ave N

Turn left onto Republican St

Continue on Republican St 1/2 block past Yale Ave

On the right hand side there will be an alleyway - Turn Right down the alleyway located between Ripple Yoga and Evolve Fitness

Within 30 feet on your right hand side, make a slight right onto the open air roof top - Park only in parking stalls labeled 'DCA' (parking stalls 20-23)

Stairs are located in the SW corner of parking lot taking you to Yale Ave (in front of stall 21)

Our clinic will be to the right of the stairway as you come down from the parking lot.

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“ If you are looking for a Dermatologist I highly recommend Dr. Mel”

– Setheni Kirschnick Seattle, WA