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

Please assist us by completing the requested information.

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

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.


Please enter your first name.
Please enter your Last Name.
Please enter your address.
Please enter a phone number where we can reach you.
Please enter a valid e-mail address. You will receive communication about this form submission at this address.


Please enter your pet's name.
OR (fill in one or the other) Enter in years & months, i.e., 5 yrs, 3 mos