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.