Owner Name
(Required)
First
Last
Pet Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
When did you first notice symptoms?
MM slash DD slash YYYY
Is this a reoccurring problem?
Yes
No
Has your pet been shaking their head or scratching their eyes or ears?
Yes
No
What product(s) do you use to clean the ears?
When was the last time you cleaned their ears?
MM slash DD slash YYYY
Have they had a recent bath or been swimming ?
Yes
No
Have you noticed any head tilting or staggering?
Yes
No
Has there been a recent diet or treat change?
Yes
No
What heartworm/flea/tick preventative is your pet on?
When was the last time it was given?
MM slash DD slash YYYY
Please send all previous records to us as soon as possible or list previous vet and we will reach out on your behalf to get them.
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