Skin Issue Questionnaire

Thank you for choosing Healing Paws Veterinary Care. Please fill out the following form as thoroughly as possible so we can better serve your pet. If you have any questions, please give us a call. We look forward to seeing you and your pet!

Name *

First

Last

Email *

Pet's Name *

Please answer these questions for what you have seen with your pet in the last 12 months.

What areas of the body are involved? *

On a scale of 1-10, 10 being licking or scratching almost constantly, how itchy has your pet been? *

Does your pet have any hair loss? If so please describe. *

Does your pet have dandruff? *

Does your pet have any odor changes, pigment/color changes or texture change to the skin or coat? *

Are the skin issues your pet is having continuous year round or seasonal? *

Year Round
Seasonal

Are your pet's signs worse indoors, outdoors, or the same in both? *

Worse Indoor
Worse Outdoor
Both

Do you know of any drug allergies that your pet has? *

Name all foods, treats, and snacks your pet currently gets? *

Since one month prior to noticing your pet's skin problems, have you made any changes in what they eat? *

Do you have any feathered items, birds, or bedding in your home? *

What other types of bedding are in your home? *

Do you have any indoor plants? If so, what types? *

Does anyone that lives in your home smoke tobacco (in or outside the home)? *

Is there carpet in your home? *

Name all types of pets in your home: *

Do any of the people or other pets in your home have any skin rashes or skin issues? *

Has your pet undergone any types of skin testing? *

(If so, please provide us with the medical records showing the testing and the results and uploading them below.)

Has your pet undergone any treatment for these skin issues? *

Has your pet ever been on medication that made them feel unwell? If so, what medication was it? *

Has your pet been on a prescription diet with no other foods in an 8 week diet trial? If so, what diet? *

Have you ever seen live fleas on your pet or any other pet in or around your home? *

What type of flea preventative do you use on your pet and when was the last time you used it? *

What type of flea preventative do you use for each of your other pets and how often do you use it? *

How often do you bathe your pet? *

Specifically, what type of shampoo do you bathe your pet with? *

Does bathing make your pet, better, worse, or no difference and, if better, how long does it help? *

How often is your pet brushed, clipped, or combed? *

What is your goal for this appointment?

Important Authorizations

Authorization to Perform Examination/Diagnostics/Treatment: I hereby authorize the Healing Paws Veterinary Care, Inc. staff and doctor to perform an examination. I understand that the condition my pet has may include them having pain or anxiety and also authorize the Healing Paws Veterinary Care, Inc. staff and doctor to provide short-term pain or anxiety relief to my pet during their stay. At the end of the examination, if the doctor feels that further diagnostic testing is necessary, the tests may be performed during my pet's visit. With the results of those tests, I understand that the doctor will personalize a treatment recommendation for my pet and then will review those recommendations with myself or my representative. I understand that receiving diagnostic testing and treatments allows my pet to feel more comfortable as soon as possible and allows the doctor to evaluate their results and treatments so that I can receive the most accurate treatment recommendation plan. *

I have read and understand this authorization and hereby accept and agree to the terms of the consent for examination pain or relaxing medication treatment as described above. I authorize the doctor and staff of Healing Paws Veterinary Care, Inc. permission to perform examination, tests, and treatments on my pet today and am responsible for the payment of these services. I understand that I will be contacted for further permission if the total of the examination, in-patient care, tests and treatments for my pets is over $500 today.
I do not give permission to perform anything other than examination with treatment for pain or relaxation until I receive the doctor’s recommendations and have signed an electronic treatment plan or paid the invoice via phone. I am responsible for the payment of the examination even if I decline any further tests or treatments. I understand that while the medical team will do their best to perform these procedures the same day if possible, the process of me receiving and returning this treatment plan may delay my pet’s testing, treatments, and discharge time or may require a second appointment to perform these procedures.

Information About Veterinary Medical Care:

I realize that no guarantee or warranty can ethically or professionally be made regarding outcomes of treatment of medical illnesses or effectiveness of preventative care products and procedures. I have been informed that there are certain risks and complications associated with disease, sedation, anesthesia, and/or any operation/procedure and that while the team at Healing Paws Veterinary Care, Inc has my pet's best interest in mind at all times, sometimes complications occur. I further understand that during the course of the examination, diagnostics, procedures, or treatments, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before treatment or diagnostics are initiated. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care. I accept that my financial obligations remain regardless of the outcome of treatment.

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute consent for examination, diagnostic testing, procedures, and treatment of said animal. I have read and understand this authorization and hereby accept and agree to the terms of the consent for examination and treatment. I understand that I am financially responsible for any services, products, or treatments provided to my pet and that I can request a treatment plan and cost estimate for my pet at the time of my visit. *

I have read and understand

Skin Issue Questionnaire

Important Authorizations

We’re here for you.

Contact Us