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Indicates a required field
Contact information:
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First Name:
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Last Name:
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Home Phone:
Cell phone:
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E-mail:
Address:
City, Zip Code:
Pet information:
Pet's Name:
Type of Pet:
Dog
Cat
Date of Birth:
Gender:
Male
Female
Spayed/Neutered:
Yes
No
Breed:
Weight:
Ear Problem:
Date of last appointment:
Which ear affected:
Right
Left
Both
Symptoms:
Itchy
Pain
Odour
Hair loss
Discharges
Crust
Ulcer
Growth/tumour
Head shaking
Progress of ear treatment:
Improvement
Worsening
No changes
Relapse
Ear medication name:
Did it help?
Yes
No
When was it stopped?
New problem:
Ear Cleaning Solution name:
Skin Problem:
Date of last appointment:
Current Skin Problem(s):
Rash
Hairloss
Itching
Odour
Other
For itchy patients:
Licking
Chewing
Biting
Scratching
Rubbing
Itching degree before treatment:
Please Select
No itching
Occasional mild itching
Frequent mild itching
Moderate itching
Prolonged severe itching
Continuous severe itching
Itching degree after treatment:
Please Select
No itching
Occasional mild itching
Frequent mild itching
Moderate itching
Prolonged severe itching
Continuous severe itching
Itching degree now:
Please Select
No itching
Occasional mild itching
Frequent mild itching
Moderate itching
Prolonged severe itching
Continuous severe itching
Progress of skin treatment:
Improvement
Worsening
No changes
Relapse
Drug History:
Drug Type
When was it started?
Did it help?
When was it stopped?
Name
Antibiotic:
Yes
No
Steroids:
Yes
No
Shampoo:
Yes
No
Flea treatment:
Yes
No
Mite therapy:
Yes
No
Atopica:
Yes
No
Immune therapy:
Yes
No
Other medications:
Food Intolerance:
Food Type
When was it started?
Did it help?
When was it stopped?
Name
Commercial Food:
Yes
No
Home Made Formula: :
Yes
No
Message:
If you want to send a picture of your pet please use email: mobilevetcare@gmail.com