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FAQ
Refer a patient
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021 0829 7975
info@vetderm.co.nz
Home
Services
The team
Preparing for your visit
FAQ
Refer a patient
Contact
New patient form (Dog)
Owner details
Main contact
First Name
(Required)
Last Name
(Required)
Email
(Required)
Phone
(Required)
Address
(Required)
Secondary contact
Name
Phone number
Email (if you would like notes sent to secondary contact as well as primary)
Animal details
Name
(Required)
Sex
(Required)
Male
Female
Desexed
(Required)
Yes
No
Species
(Required)
Dog
Cat
Breed
(Required)
Age / Date of birth
(Required)
Weight
(Required)
How long have you had your pet?
Where did you get your pet from?
Previous vets
Previous vet clinics
(Required)
Pet insurance?
(Required)
Yes
No
Pet insurance company:
Animal lifestyle & environment
Current diet (including treats):
(Required)
Supplements
Previous diets (including diet trials for skin)
Current flea treatment brand
(Required)
Flea treatment type
(Required)
Topical / Spot-on
Oral
Other
Date last flea treatment given
(Required)
Have you ever seen fleas or flea dirt on your pet?
Percentage of time spent indoors:
(Required)
Other pets in household:
(Required)
Exercise (how often, where):
Swimming (where, how often):
Animal behaviour
Your pet’s emotional wellbeing is important to us. Please tell us about your pet’s behaviour.
How stressed / anxious does your pet get during vet visits?
(Required)
Not stressed
Mildly stressed
Moderately stressed
Very stressed
Please provide details:
Are there any areas on your pet’s body that they dislike having touched or examined?
Are there any procedures / situations that make your pet anxious, uncomfortable or react negatively?
Any other information regarding your pets behaviour that you would like us to know about?
Current skin problem
Main problem (what are you noticing?)
(Required)
Area(s) of the body currently affected
(Required)
When did the problem start?
(Required)
Where on the body did you first notice the problem?
(Required)
Has your pet had skin problems before?
(Required)
Please describe
This field is hidden when viewing the form
Has your pet had skin problems before?
(Required)
Yes
No
Is the problem getting worse?
(Required)
Current level of itching (includes scratching, licking, nibbling, chewing, shaking head, scooting)
(Required)
No itching / Normal dog
Very mild / Only occasional episodes
Mild / A bit more frequent (No itching when eating, playing, exercising or being distracted)
Moderate / Regular episodes (Can itch at night but NOT when eating, playing, exercising or being distracted)
Severe / Prolonged episodes (Can itch at night and ALSO during eating, play, exercise or when distracted)
Extremely severe / Almost continuous (Itching doensn't stop whatever is happening, needs to be physically prevented from itching)
Which part(s) of the body does your pet itch the most?
Does your pet appear distressed or in pain? (if so, please describe:)
Any other health problems or concerns?
Medications / Treatments
Current oral medications
(Required)
Bathing Routine
(Required)
Current topicals (creams, ointments, sprays)
(Required)
Have any current or previous treatment(s) helped?
Gut symptoms
(Some dogs with food allergy have gastro-intestinal symptoms, as well as skin problems)
Number of bowel movements per day:
(Required)
1-2
3 or more
Don't know (faeces not seen regularly)
Have you noticed any of the following (even if mild or intermittent)?
Diarrhoea or soft faeces
Mucous (slimy) faeces
Straining to pass faeces
Scooting (rubbing bum on ground)
Flatulence (passing wind / gas)
Vomiting / Regurgitation
How often are the symptoms above observed on average?
Most days
Once a week
Once a month
2-3 times per year
Additional comments about gastro-intestinal symptoms
Photos
Photos are extremely helpful
Upload photos of skin problem &/or general photo of your pet
Drop files here or
Select files
Max. file size: 100 MB.
Alternatively, send later via email, text, imessage or whatsapp (info@vetderm.co.nz / 021 0829 7975)
This field is hidden when viewing the form
Do you give consent for photos of your pet to be shared on our social media or website?
Y
N
