Recheck Visit Form

    Owner and Patient Information

    Last Name*

    First Name*

    Phone Number

    Email

    Pet Name*

    History

    Have you noticed any changes in your pet's condition since their last appointment - good or bad?*

    Does your pet focus on any of the following issues?

    Which parts of its body does your pet focus on?

    What is your pet's current itch score?

    Moderate Itching (Frequent Episodes):
    My dog is itching occasionally throughout the day but is not itching while eating playing, sleeping or whie being distracted. Itching ensues at night when observed.

    Medications

    Current Medications: names, doses and frequency. Length of prescription. Any other details.

    Habits and Diet

    Fecal Score*

    Frequency/number per day?

    What is your pet currently eating? Include treats, human food, and / or supplements.*

    Additional Information

    What are your goals for your upcoming appointment?*

    Relevant Images of Skin or Medical History

    Files must be smaller than 5mb. If your file is larger than 5mb, please email it directly to referrals@petderm.ca.

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