Pet Skin Condition Report Form
Report and document your pet's skin condition to assist veterinary assessment.
Owner's Full Name
*
First Name
Last Name
Owner's Email Address
*
example@example.com
Owner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Pet's Name
*
Species
*
Please Select
Dog
Cat
Other
Breed
Pet's Age (in years)
Pet's Gender
Male
Female
Unknown
When did you first notice the skin condition?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where on the body is the skin condition located? (Select all that apply)
*
Face
Ears
Neck
Back
Abdomen
Legs
Paws
Tail
Other
Please describe the skin condition (appearance, color, texture, etc.)
*
Has the condition changed over time?
Improved
Worsened
Stayed the same
Is your pet experiencing any of the following symptoms? (Select all that apply)
*
Itching/Scratching
Redness
Hair loss
Scabs/Crusts
Sores/Ulcers
Oozing/Discharge
Odor
Other
Have you tried any treatments or medications? If yes, please specify.
Does your pet have any known allergies or other health issues?
Are other pets in the household affected?
Yes
No
Not applicable
Please upload clear photos of the skin condition (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Report
Should be Empty: