Embed Size (px)
Citation preview
Riverdale Veterinary DermatologyPreparation for Appointment
�
Collect ALL medical records: they need to be faxed or e-mailed to the office PRIOR to your visit. (some veterinary hospitals will do this directly from their office)
�
Arrive 15 – 20 minutes early so we can process any necessary paperwork.
�
Bring actual medications or list any pertinent medications. If you have any x-rays films, etc., please bring them as well.
�
Please try to not bathe your pet the week before your initial visit. If your appointment is scheduled for less than a week, do not bathe until your visit.
�
If you have an AM appointment, pet should be fasted for the appointment. **Diabetic patients don’t need to be fasted
� If you need to cancel or reschedule your appointment, please give us 24 hours to avoid a cancellation fee.
A consultation is necessary prior to any procedure (i.e. intradermal skin testing, video otoscopy, etc) so that your pet may be thoroughly evaluated.
82 Newark Pompton Tpke, Riverdale NJ 07457 * (973) 831-2383 * Fax (973) 907-2818 * [email protected]
Dermatology Admission Form Dr.AndrewRosenbergDr.NoelRadwanski Riverdale Veterinary Dermatology
Client Information Last Name _____________________________ First Name _____________________________________
Street Address _________________________________________________________________________
City _____________________________ State ________________ Zip ______________________
Home Phone ( ) ________________________ Cell Phone/Other ( ) _____________________
Email Address: ___________________________________________________________________________ (Wewillnotsellorshareyouremailaddress.Forcommunicationpurposesonly.)
Pharmacy Name _________________________ Phone Number ( ) _________________________
Pleaselistanypersonwhoisauthorizedtomakemedical&financialdecisionsregardingthispatient
Name________________________________PhoneNumber()______________________
Name________________________________PhoneNumber()______________________
Name________________________________PhoneNumber()______________________
Patient Information Patient’s Name ____________________________ ☐ Canine / ☐ Feline ☐ Indoor ☐ Outdoor
Breed ___________________________________ ☐ Male ☐ Neutered / ☐ Female ☐ Spayed
Age __________________ Weight ________________ Color __________________
Referral Information Regular and/or Referring Veterinarian ____________________________________________________
Hospital Name ____________________________________ Phone Number ( ) ________________
Authorization & Payment Policy I hereby authorize the veterinarian to examine, prescribe or treat the above patient. I assume full responsibility for all changes incurred in the care of this animal. I also understand that these charges are to be paid in full at the time of release. Payments are expected when services are rendered. WE DO NOT BILL. In order to provide the best care, we accept: all major credit cards (MasterCard, Visa, Amex, & Discover), personal checks, Care Credit, and cash. Should collection and/or attorney’s fees become applicable I will be held responsible for those and all other costs of collection. By signing below, I hereby state that I am the owner or authorized agent of the above patient. We are teachers in the field of veterinary dermatology. Medical files, case information and/or photos may be used in teaching, continuing education, website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; client confidentiality (Names and Personal Information) will be maintained. I understand that no guarantee can be made as to the result obtained from medical treatment. I have read the above terms and conditions and agree to adhere to this agreement. Please sign below if you accept the terms above. Signature: _____________________________________________________ Date: ___________________
82 Newark Pompton Tpke, Riverdale NJ 07457 * (973) 831-2383 * Fax (973) 907-2818 * [email protected]
Please be advised that for all initial visits we require at least one owner present
What skin problem are you bringing your pet in for? How long has the problem been present?
How old was your pet when the problem first started?
When the problem started, did it come on suddenly or gradually over a period of time? What did the skin or ear problem look like initially? How has it changed or spread?
Does your pet scratch, rub, chew, lick, or bite any of the following areas? �Nose �Muzzle �Eyes �Back Paws �Chest
�Back �Front Legs � Rump �Tail �Abdomen �Back Legs �Ears �Neck �Front Paws �Armpits �Groin �Inner Thighs & Legs
Does your pet do any of the following? If yes, list frequency and description:
Cough Runny eyes Diarrhea Loss of appetite Urinate excessively
�Yes �No ________________________ �Yes �No ________________________ �Yes �No ________________________ �Yes �No ________________________ �Yes �No ________________________
Sneeze Get ear infections Vomit Drink excessively Limp
�Yes �No ____________________________ �Yes �No ____________________________ �Yes �No ____________________________ �Yes �No ____________________________ �Yes �No ____________________________
Have the problems been? (check one)
Continual, but better
when on medications �
Continual, even with
medications �
Intermittent or Sporadic
�
Is the problem worse during certain times of the year? �Yes �No
If so, when?
Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease?
Scale 1 -10 (1 occasional scratch, 10 constant, severe scratching) 1 2 3 4 5 6 7 8 9 10
How itchy has your pet been over the past month?
Scale 1 -10 (1 occasional scratch, 10 constant, severe scratching) 1 2 3 4 5 6 7 8 9 10
Please list ALL medications your pet is currently taking (include supplements, topicals, etc.) When were they last given?
Did any of the medications help the problem?����Yes �No
Which medications?
What do you feed your pet now?
Please circle the number of bowel movements your pet has per day: 1 2 3 4 5 6
Have any different diets been tried as
treatment?������Yes �No
If so, list the brand name and for how long was it given?
Has your pet received treatment for stomach or intestinal problems? �Yes �No
If yes, explain?
How often do you usually bathe your pet?
When was the last time you saw a flea on your pet or another pet in the household? What flea, tick, and heartworm prevention products are you using on your pet (list type)? Do any of the other pets or humans in the household have skin problems? What other pets are in the household? Other than skin disease, does your pet have any diagnosed medical problems? Are there any other symptoms that your pet has that have not ben described above, or is there anything else you think might be contributing to your pet’s skin or ear disease?
Do you or a family member work in the health care field? �Yes �No
If yes, what is the occupation?
