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Driver's License/ ID # (required)
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E-Mail Address (required) :
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Breed (required)
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Date of birth / Age (required)
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Color Coat & Nose (required)
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Current Food Brand (required)
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Additional Supplements (required)
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Does your pet get "Human" food? If yes, Please list the typical food items shared. (required)
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Does your pet ever vomit? If yes, How often per week? (required)
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Does your pet have intermittent soft stool (diarrhea)? (required)
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Is your pet flatulent (gassy)? (required)
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Does your pet cough or wheeze during hay fever season? (required)
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What brand of shampoo do you use on your pet? (required)
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How often do you bathe your pet? (required)
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What heartworm prevention is your pet on? (required)
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What flea & tick prevention is your pet on? (required)
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Date of last intestinal parasite screen (fecal exam): (required)
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Date of last vaccinations: (required)
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What diseases was your pet vaccinated for?
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Does your pet spend most of it's time Indoors, outdoors or both equally? (required)
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How often do you clean your pets bedding? (required)
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Current Problem: Be as detailed as possible. (required)
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When did this problem start happening? (required)
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Does your pet get weekly ear cleanings? (required)
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What ear cleanser do you use on your pet's ears? (required)
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Does your pet have abnormal appearing gums or lips? (required)
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Does your pet have red weeping eyes - conjunctivitis (required)
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Does your pet: Mark all that apply: :
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In the space provided please describe these "itchy" behaviors. Include photos if possible. (required)
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Did sore develop from your pets itching or did itching develop from sores? (required)
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Is your pet's skin red? (required)
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If yes, Describe these areas. Include detail & photos if possible. (required)
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Do these red spots look like pimples (on humans) or like a sunburn? (required)
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Are there excoriations or epidermal collarettes (scabs or crusts) in the affected area? (required)
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Is seborrehea sicca(white flaky skin) present? (required)
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Are your pet's feet red or brown between the toes or toe pads? (required)
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Describe what your pet's toe nails, nail beds, and toe pads look like. (required)
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Where did the itching first occur? (required)
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When did you notice the first sores? (required)
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Where else did the itching spread to? (required)
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Do you have other pets at home? If so, what kind? (required)
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Do those pets have skin problems? (required)
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Were these animals present before the affected pet started showing signs? (required)
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Has your pet been in contact with other animals? (required)
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If yes, did you notice if these other animals having poor coat or skin conditions? (required)
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Have you traveled away from your home since this skin problem started? (required)
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If yes, where did you travel to? Please, include trips outside the US. (required)
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