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Pet's Name:
Owner's Name:
Email Address:
Phone:
My pet lives:
Indoors
Outdoors
Both
Diet information (brand, type, quantity and schedule):
Any changes in your pet's diet?
Yes
No
Do you feed your pet people food?
Yes
No
Is your pet eating and drinking normally (check all that apply)?
Yes
No, eating less
No, eating more
No, drinking less
No, drinking more
Any weight change?
Weight
gain
Weight
loss
No
change
Is your pet scratching?
Yes
No
Please give details regarding location, duration and severity (on a scale from 1-10, 1 = very little scratching and 10 = severe scratching):
Is your pet chewing?
Yes
No
Please give details regarding location and duration:
Have you changed laundry detergent recently?
Yes
No
Have you sprayed the house or yard lately?
Yes
No
Any new pets in the household?
Yes
No
Has this issue happened before?
Yes
No
Does it seem to be a seasonal occurrence, year-round or random?
Seasonal
Year-round
Random
Does your pet receive routine ear cleaning and/or bathing (check all that apply)?
Routine bathing
Routine ear cleaning
Neither routine bathing or ear cleaning
Is your pet currently taking a monthly heartworm preventative?
Yes
No
Brand of heartworm preventative:
Is your pet currently taking a monthly flea/tick preventative?
Yes
No
Brand of flea/tick preventative:
Is your pet currently taking any medications or supplements?
Yes
No
Please list all medications/supplements with dosage and frequency of administration:
Please provide any additional information that may be helpful for us to know about your pet:
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