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Admission Form

Completing the form below gives our veterinary team the insights they need to provide the best care possible.

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Admission Form

The Admission Form is a required questionnaire about your pet’s history for Dr. Williamson and Dr. Shumaker to review prior to your appointment. Before completing the Admission Form, please read the What to Expect, Frequently Asked Questions, Cancellation Policy, and Prescription Policy sections under the “For Patients” tab.

Be sure to set aside about 20-30 minutes to complete the form in one sitting as it will not save your progress if you have to leave the page for any reason.

The Admission Form must be received at least one week prior to the consultation in order to keep the scheduled appointment.

Admission Form

Owner Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Owner's Name(Required)
Spouse's/Co-Owner's Name(Required)
Address
Communication Method(Required)

Your Pet's Basic Information

Pet's Species(Required)
Sex(Required)
Prior to being referred to Veterinary Dermatology of Richmond, Please list below all of the veterinary clinics that you have taken your pet to within the past 3 years including emergency clinics. We will be asking for a copy of the records

Your Pet's Medical History

Has the problem been intermittent or continuous?(Required)
If the problem is intermittent, is it seasonal?(Required)
If the problem is continuous, is it exacerbated during certain seasons?(Required)
If your pet is scratching, chewing, rubbing or licking, where is it occurring?(Required)
Is your pet losing hair?(Required)
Have you seen red bumps on your pet?(Required)
Does your pet have a history of ear infections?(Required)
Are there other pets in the house?(Required)
Are any of the other pets having similar problems?(Required)
Has your pet ever traveled outside the state of Virginia?(Required)
Does your pet receive flea control?(Required)
Are all pets in the household receiving flea control at the same time?(Required)
Is your pet on heartworm preventative?(Required)
Are you concerned about diseases transmitted by fleas?(Required)
Are you concerned about diseases transmitted by ticks?(Required)
Are you concerned about diseases transmitted by mosquitoes?(Required)
Does your pet have a history of any of the following (Check all that apply)(Required)
Does your pet ever have exposure to cats?(Required)
Does your pet ever have exposure to horses?(Required)
Does your pet ever have exposure to tobacco products?(Required)
Are you concerned about giving your pet steroids?(Required)
Have You Read The What To Expect Section?(Required)
Have You Read The Frequently Asked Questions Section?(Required)
Have You Read The Cancellation Policy Section?(Required)
Have You Read The Prescription Policy Section?(Required)
If you feel you have completed all fields successfully, please click SUBMIT below.