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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 (Cat)
Owner details
Main contact
First Name
(Required)
Last Name
(Required)
Email Address
(Required)
Phone Number
(Required)
Address
(Required)
Secondary contact
Secondary Contact Name
Secondary Phone number
Secondary Email (if you'd like notes to be emailed to secondary contact as well)
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 owned your cat?
Where did you get your cat from?
Previous vets
Previous vet clinics
(Required)
Pet insurance?
(Required)
Yes
No
Pet insurance company:
Animal lifestyle & environment
Current diet (including treats & supplements):
(Required)
Previous diets
(Required)
(including special food trials)
Current flea treatment brand
(Required)
Date last flea treatment given
(Required)
Have you ever seen fleas or flea dirt on your pet?
Percentage of time spent indoors:
(Required)
Is your cat kept indoors at night?
Other pets in household:
(Required)
Does your cat hunt?
Does your cat use a litter box or have one available?
Have you noticed any of the following (even if mild or intermittent)?
Diarrhoea or soft faeces
Mucous (slime) or blood in faeces
Straining to pass faeces / Constipation
Scooting (rubbing bum on ground)
Vomiting
Hairballs
If yes to any above, how often are the signs observed?
Animal behaviour
Your pet’s emotional wellbeing is important to us. Please tell us about your pet’s behaviour.
How stressed or anxious does your cat get with travel / vet visits?
(Required)
Not stressed
Mildly stressed
Moderately stress
Very stressed
Please provide details:
Are there any other situations that may cause your cat to be anxious, stressed or react negatively?
(Required)
Can you medicate your cat orally?
(Required)
Any other information regarding your cat's 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
Is the problem getting worse?
(Required)
Current level of itching (includes licking, over-grooming, scratching, chewing)
(Required)
No itching / Normal cat
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)
Current topicals (creams, ointments, sprays)
(Required)
Have any current or previous treatment(s) helped?
Photos
Photos are helpful to describe what words can't
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)
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Do you give consent for photos of your pet to be shared on our social media or website?
Y
N
