Ear/Skin Form

How long has the skin/ears been a problem? *

Pet's name: *

Do you give your pet any supplements? *

Yes

No

Phone: *

What type of shampoo do you use? *

Has there been any lapses in prevention doses? *

Yes

No

What type of food do you feed your pet? *

If yes, what is the time and date?

How often do you bathe your pet? *

Do you already have an appointment scheduled? *

Yes

No

What is the main source of protein (meat) in the food? *

What previous medications/foods have been used to treat the problem?

Are there any specific lesions? *

Yes

No

What type of heartworm/flea prevention do you use and when was the last dose? *

If yes, what kind and how often?

If yes, where are they located?

Name: *

If yes, where does your pet scratch/itch the most?

How much and how often? *

Is your pet itchy? *

Yes

No

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