Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Phone *

Secondary Phone

Pet Information

Pet's Name *

Age or Date of Birth *

Breed *

Species *

Dog
Cat

Sex *

Male
Female
Neutered Male
Spayed Female

Current on vaccines? *

Yes
No

Please provide date of last rabies vaccine. *

Does your pet require antianxiety medication to facilitate veterinary examinations? *

Yes
No

If yes, please administer as directed by your veterinarian.

Current Weight *

What is the primary problem for today’s appointment? *

When did this problem first start? *

Please list your pet's current symptoms

List any medications previously and/or currently tried for this condition

What other pets are in the household? *

Do any other pets or people in the household have skin problems?

Yes
No

Other than skin and/or ear disease, does your pet have any diagnosed medical problems?

Yes
No

If yes, please list those diagnoses here.

Are there any other comments you would like us to know about your pet’s skin and/or ear disease?

Kindly upload any relevant medical reports or photos of your pet that may aid our veterinarians in providing the best care. Your pet's information is safe and will only be used for medical reference.

Click or drag a file to this area to upload.

Payment Information

ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED, AND DEPOSITS ARE REQUIRED ON ALL HOSPITALIZED PATIENTS. I will be paying by

Cash
Check
Credit Card (Visa, Mastercard, Discovery or American Express)

New Patient
Intake Form

New Patient
Intake Form

Patient Intake Form

Ready for a visit?

Questions?

Location

Contact Information

Hours

We proudly serve the pets of southeastern Wisconsin & beyond.

New PatientIntake Form

New Patient Intake Form

Patient Intake Form

New Patient
Intake Form

New Patient
Intake Form