Please complete your new client form prior to your first appointment. We look forward to meeting you soon!

Owner’s Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Home Phone*

Which number is best to reach you?*

Cell
Home

Can you receive text messages?*

Yes
No

Email*

Add a Co-Owner/Alternate Contact?

Yes
No

Co-Owner/Alternate Contact Name

First Last

Cell Phone

Pet Health History

Pet’s Name*

Sex*

Female
Male

Neutered/Spayed?*

Yes
No

Breed*

Color*

Birthdate or Age*

Is your pet currently covered under pet insurance?*

Yes
No

When did the problem start?*

What is the main reason for your visit?*

Was the problem sudden in onset, or slow?*

Sudden
Slow
N/A

Is there a seasonal influence?*

Yes
No

If seasonal, what seasons are worst? Check all that apply.*

Spring
Summer
Fall
Winter
N/A

If not currently seasonal, was it previously seasonal?*

Yes
No

Where on the body did the problem start?*

Describe how the condition has worsened.*

Are any other pets or people in the house affected with skin problems?*

Yes
No

On a scale of 1-10, 1 being slightly itchy and 10 being extremely, how itchy is your pet?*

Has your pet had any recent chronic digestive problems? (diarrhea, vomiting, excessive gas, increased defecation) Describe:*

What is your pet’s current diet, as well as any previous diets?*

Medical history: Previous non-skin diseases, treatments, results:*

List any CURRENT medications (including dosages) and any supplements, shampoos, ointments, including over the counter your pet is taking:*

Which treatments have been most helpful?*

What is your pet’s CURRENT flea and heartworm prevention?*

Please check below if any of the following medications have been tried and helped. Check all that apply.*

Cytopoint
Apoquel
Steroids
Cyclosporine
Zenrelia

Have you noticed your pet do any of the following? Check all that apply.*

Rubbing
Scooting
Chewing
Licking
Head shaking
Scratching at ears
Scratching
Excessive grooming

If you checked yes to any symptoms above, are they: Check all that apply.*

Constant
Sporadic
Only at night

Please check below if any of the following are present or have occurred in the past. Check all that apply.*

Is there anything else that you think would be helpful for us to know?*

Is your pet aggressive or fearful around strangers?*

Yes
No

Is your pet up to date on their vaccinations?*

Yes
No

Office Policies

At Capital Area Veterinary Specialists, we operate by appointment only to allow for ample time to address all concerns for every patient. To maintain efficiency, we ask that clients arrive on time for all appointments and procedures. If you are more than 15 minutes late, you may be asked to reschedule your appointment.

If you need to cancel an appointment, please provide at least 48 hours' notice. This allows us to accommodate other patients in need of timely care.

No Show Policy (Dermatology Service Only): Due to high demand and limited availability, clients who fail to show up for an appointment or cancel on the same day will be required to leave a $100 deposit before scheduling future appointments. This deposit will be applied to the cost of services but is non-refundable within 48 hours if you cancel or miss your appointment.

For the safety of all pets and clients, we require that all animals entering our facility be properly restrained on a leash or in a carrier. If assistance is needed, please request help upon arrival.

Capital Area Veterinary Specialists require payment in full at the time of service. We accept all major credit cards, debit cards, and cash, but we do not accept checks. Additionally, we offer financing options through CareCredit to assist with pet care expenses.

Reminder: Our team is made up of dedicated professionals who are committed to providing the best care for you and your pets. We ask that all clients treat our staff with respect. We have a zero-tolerance policy for profanity, verbal threats, bullying, or any form of violence or aggression toward our staff or other clients. Such behavior will not be tolerated, and we reserve the right to refuse service to anyone who violates this policy.

Acknowledgements

At Capital Area Veterinary Specialists, we strive to utilize the most up-to-date technology in caring for our patients. In some cases, photographing your pet or their condition may be necessary for documentation purposes. We are committed to protecting client and patient information with the highest level of security.

Additionally, we love celebrating our patients’ successes and may feature them on our social media platforms. I grant Capital Area Veterinary Specialists permission to use photos of my pet on social media, the clinic’s website, or any other media related to its business.

Yes
No

By signing below, I confirm that the information provided above is accurate to the best of my knowledge. My signature acknowledges that I am at least eighteen years old and either the owner or an authorized agent of the pet listed. I grant permission to the attending veterinarians at Capital Area Veterinary Specialists to examine and treat my pet.

I accept full responsibility for all charges incurred for my pet’s care. I understand that payment is required in full at the time of service and must be made in advance for hospitalization, treatment, and/or procedures. Any financial concerns should be addressed before my pet's examination or treatment.

I have read and understand*

Yes
No

Owner's Signature*

Date*

Comments

This field is for validation purposes and should be left unchanged.

(Dermatology) New Client Form

Pet Health History

Office Policies

Acknowledgements

Visit Us

(Dermatology) New Client Form

Pet Health History

Office Policies

Acknowledgements

Visit Us

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