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New Patient Form

Save time during your next appointment! Complete your required new patient forms online from any device at any time before your visit.

New Patient Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Please have this form completed and submitted prior to your pet’s first appointment

Owner's Name

Name *

First

Last

Email *

Pet's Name *

Date of birth or approximate age *

Sex *

Is your pet neutered or spayed? *

Yes
No

Type of Pet *

Dog
Cat

Breed *

Color *

Please list all veterinary offices visited in the past two years *

How long have you owned your pet? *

Has your pet traveled outside the immediate area in the past 2 years? If so, please specify here *

What is the primary problem for today’s appointment? *

When did this problem first start? *

Does your pet have any of the following symptoms? Click all that apply.

Ear infections
Sneezes
Runny nose
Watery eyes
Cough
Diarrhea
Frequent bowel movements (more than 3x a day)
Flatulence (gas)
Butt Scooting
Decrease/Loss of appetite
Vomiting
Drink excessively
Urinating excessively (accidents in the household)
Ataxia (Impaired balance/coordination)
Lameness (Limping)

If yes to any of the above, please list the frequency and description. *

How old was your pet when the problem first started? *

When the problem first started, it began: *

Suddenly
Gradually over a period of time

Does your pet scratch, rub, lick, chew, or bite any of the following areas? *

Nose/muzzle
Eyes
Ears
Paws
Front legs
Back legs
Abdomen
Chest
Armpits
Back
Genitalia
Rump
Inner thighs
Tail

These problems have been: *

Continuous, improved with medication
Continuous, no improvement with medication
Sporadic (symptoms wax and wane)

What time of year is the problem worse? (Select all that apply) *

Summer
Fall
Winter
Spring
Year Round

On a scale of 0 (never itchy) to 10 (constant, severe itchiness), how itchy is your pet currently? Select value: 0-10

Is your pet currently taking any medication? *

Yes
No

Did any of the medications help the problem? *

Yes
No

Please list any medications your pet is currently receiving:

How itchy has your pet when receiving medications for itch relief? Selected Value: 0-10

What diet do you feed your pet currently (Please include not just the brand name but protein source, ex. Purina Pro Plan Chicken or Royal Canin Rabbit)? *

How many bowel movements does your pet have per day? *

Have any prescription diets been tried as a treatment to rule out food allergies? *

Yes
No

Has your pet been treated for gastro-intestinal problems? *

Yes
No

What flea, tick, and heartworm prevention products are you using on your pet? * (Please list name of products and last time it was given) *

Do any other pets or people in the household have skin problems? *

Yes
No

What other pets are in the household? *

Other than skin and/or ear disease, does your pet have any diagnosed medical problems? *

Yes
No

Is anyone in the household immunocompromised? *

Yes
No

Are there any other comments you would like us to know about your pet’s skin and/or ear disease?

Comment

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We’re excited to meet you

We proudly serve the pets of Chicago and the surrounding areas. We look forward to seeing you and your pet! You may request an appointment by giving us a call at 312-929-2934.

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Get in Touch

Phone: 312-929-2934
Email: [email protected]

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Where to Find Us

1030 N. Larrabee Street
Chicago, IL 60610

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Our Hours

Monday 8:00am-5:00pm

Tuesday 8:00am-5:00pm

Wednesday 8:00am-5:00pm

Thursday 8:00am-5:00pm

Friday 8:00am-12:00pm

Have a question? Complete our online form, and we will be in touch with you shortly.

Name *

First

Last

Email *

Phone

How can we help you? *

Comment

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