Veterinary Dermatology Patient History

University of Minnesota Veterinary Medical Center Dermatology Client/Patient Questionnaire header

email: vetderm@umn.edu

Please assist us by completing the requested information.

Please note that fields with an asterisk (*) are required fields.

If you receive any errors pertaining to this form, please screenshot the error messages and send them to cronk005@umn.edu
The University IT system has upgraded some of our processing software in the end of January and we have occasionally been having issues. Please also note the browser (chrome, safari, firefox, edge) you're using and the type of device (i.e., iPhone, Android, PC, Mac, etc).

The following form has been broken out into 6 sections. At the end of each sectiton you will be able to save before going on to the next section. The sections are broken down into:      Section I: Client/Patient Information
     Section II: History
     Section III: Medical History
     Section IV: Dermatologic Symptoms
     Sectiton V: General Symptoms
     Sectiton VI: Other Questions

Upon completion of the Other Questions section you will have a chance to review all of your answers. After you have reviewed them you will be asked to Submit your form. Upon submission you should receive an email at the email address you have provided in the Client Informatiotn section. The form is also submitted to the University of Minnesota Veterinary Medical Center Dermatology Department for review.

UMN PA Number / Case Number

Appointment Date

Appointment Time

CLIENT INFORMATION

Client First Name*

Please enter your first name.

Client Last Name

Please enter your Last Name.

Client Address

Please enter your address.

City

State

Zip Code

Phone Number

Please enter a phone number where we can reach you.

E-mail

Please enter a valid e-mail address. You will receive communication about this form submission at this address.

PATIENT INFORMATION

Pet's Name

Please enter your pet's name.

Species

Breed

Gender

Birthdate or Age OR (fill in one or the other) Enter in years & months, i.e., 5 yrs, 3 mos

REASON FOR VISIT

Reason for Visit

Expectations for Visit