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New Patient Form Client Information Household/Environment Details Client: SUZANNE OWINGS Email: [email protected] Phone: 770-942-3303 Other Pets: No YES Other Pets Affected : No NO Littermates or Parents Affected: No NO People in Home Affected: No NO Pet Information Flea Control / Bathing Pet's Name: CARSON Date of Birth: 06/25/2009 Date Acquired: 09/25/2009 Spayed: 01/15/2011 Condition Flea Control on Pet: No NO Environmental Flea Control in Home/Yard: No FLEABUSTERS How Often Pet Is Bathed: EVERY 60 DAYS Shampoos/Bathing Products: BUDDY WASH AND CONDITIONER Diet Complaint: SPOT ON NOSE Problem Started: 08/13/2012 Time Spent Indoors: 75% Condition is Currently: continuous Was It Initially Seasonal: no Time Condition is Less Severe: No NO Occasions Symptoms are Worse: No ALWAYS THE SAME Diet - Foods & Treats: RAW MEAT AND ORGANIC KIBBLE How Long On This Diet: 3 YEARS Vitamins or Supplements: OMEGA 3 & PITCARIN'S HEALTHY POWDER Bowel Movements Daily: 2 Onset and History of Symptoms Previous Treatments First indications of problem: redness Where did the problem start: nose Areas pet may scratch, rub, check, lick or bite? Has Problem Spread? No NO How Itchy: 1 out of 10 Medications For Skin Condition: NO Other Medications: NO Medications That Helped: No NO Times Treated for Condition: 0 Treated for Stomach or Intestinal Problems: No NO Symptoms Pet Exhibits Clinic Cough: No Runny Nose: No Diarrhea: No Loss of Appetite: No Urinate Excessively: No Sneeze: No Ear Infections: No Vomit: No Drink Excessively: No Limp: No Animal Dermatology Clinic 1453 Terrell Mill Rd SE, Suite 119 Marietta, Georgia 30067 Phone: (770) 422-2509 Fax: (770) 422-8750 Email: [email protected] Please bring, email or fax this document to the clinic selected above.
