Dermatology Questionnaire

Dermatology - New Patient Questionnaire

Your Information

Your Pet's Information

4. What other pets do you have living in your household? *
e.g.: 25% outdoors, 75% indoors
11a. Where on the body does this occur? *
12b. If your pet is NOT itchy year round, which season(s) are they itchy? *
21. Which of your pets receive flea preventative?
23. Is your pet up to date on vaccines?

24. Please list all the medications and ear/skin topicals your pet is currently receiving or has received in the past

(if you have multiple medications, please fill the fields below for the first medication, then click the "add" button at the bottom to respond to all fields for the 2nd medication, and so on)
26. Do you give permission for Golden Gate Veterinary Specialists to post photos of your pet on our website or social media? *