Name: Animal Allergy and Ear Clinic
Address: 13025 SW Millikan Way Suite 100, Beaverton, OR, 97005, United States
Telephone: 503-574-4150
Price range: $

Which clinic will you be visiting? *

Beaverton, OR
Greensboro, NC

Have you scheduled an appointment yet? *

Yes
No

If you do not yet have an appointment, please call the AAEC office at 503-574-4150 to schedule one. Thank you!

What day is your scheduled appointment? *

Your Pet’s Name *

Pet Owner Information

Your Name *

First

Last

Spouse/Partner’s Name

First

Last

Your Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Cell or Landline *

Phone Name (Example: Max's Cell or Jenny's Work") *

Secondary Phone

Cell/Landline/Name (example Max's Cell or Jenny's Work")

Phone Name (example Max's Cell or Jenny's Work") *

Work Phone Number

Cell/Landline/Name (example Max's Cell or Jenny's Work")

Phone Name (example Max's Cell or Jenny's Work") *

Email Address *

How did you hear about us? *

Please specify. *

Patient Information

Species *

Dog
Cat
Horse

Sex *

Male
Female

Is your pet spayed or neutered? *

Yes
No

Breed or Mix *

Date of Birth or Approximate Age *

Color *

Weight *

Any known allergic or drug reactions? *

Primary Veterinarian

Clinic Name and City (In the case of a clinic with multiple locations please provide the address or cross streets to identify which location)

Doctor Name

Office Phone Number

Please Note: Any unpaid balance may accrue at an interest rate of 1.00% per month. Clients may be charged a fee for cancelling their appointment without at least 24-hour notice. *

I have read and acknowledge these terms and conditions

Food and Treats

What brand of food do you feed your pet?

What flavor is the food? (chicken, salmon, vegetarian, etc.)

Do you feed your pet treats? If yes, please list all the types of treats.

How many bowel movements does your pet have each day?

Has a prescription elimination diet trial been tried to rule out food allergy?

Yes
No

Please list the specific food and how long it was fed.

Was your pet on heartworm or flea prevention at the time of the food trial?

Yes
No

Please list the brand of heartworm and/or flea prevention.

Dermatological History

What is the current concern? *

At what age did your pet’s problem start?

What other types of pets are in the household?

Is the problem seasonal?

It hasn’t been long enough to know
No, the problem is constant all year long
Yes

Please specify. *

Is your pet itchy? (scratching, licking, chewing, rubbing, rolling, biting)

Yes
No

Is the itching worse at any specific time of the day or night? *

Yes
No

Please give a brief description. *

What primary parts of your pet does he or she scratch/chew/rub/lick?

Are there any other pets or household members who are experiencing similar skin issues?

Yes
No

If your pet has skin and ear issues, which started first?

Skin
Ears

Environmental Questions

Is there an increase in symptoms while cleaning the house with the pet indoors?

Yes
No

Where does your pet sleep and on what type of material (wool, cotton, cedar chips, etc.)?

Does your pet have any known sensitivities or allergies to topical medications or products? (examples shampoos, eye drops, ear ointments, etc.).

Yes
No

Please describe. *

Treatments

Other than the skin and/or ear problems we will be seeing your pet for, does he/she have any other medical conditions we should be aware of such as heart disease, diabetes, epilepsy, etc.? *

Yes
No

If yes, what is the condition? *

Does your pet take any medications, supplements, or nutraceuticals on a regular basis? *

Yes
No

If yes, please list these including the strength of the drug or supplement and how often it is given (if known). *

Missed and/or Late Appointment Policies

We reserve the right to charge a missed appointment fee equal to the consultation charge for any appointment no-show or cancellation with less than 48 hours notice as they prevent another pet from being seen during that appointment time.

If at any point you know that you will not be able to make your pet’s scheduled appointment please notify us, as even if the 48 hour window has passed we may not charge the missed appointment fee if we are able to fill your appointment time with a patient from our waitlist.

Also, please be aware that you may be forced to reschedule and/or incur a missed appointment fee if you are more than ten minutes late depending upon the type and length of the scheduled appointment.

Pet Insurance

It is your responsibility as the pet owner to submit your paid invoices to the insurance company for reimbursement. We will provide you with the appropriate paperwork to submit to them so let us know in advance if you have pet insurance.

The Need to Do Cytologies

Many patients we see have secondary infections of the skin and/or ears, meaning they have a bacterial and/or yeast infection resulting from an underlying dermatologic condition such as allergies, hypothyroidism, auto-immune disease, or Cushing’s Disease. It is necessary to identify and treat these infections in order to diagnose the underlying health problem. This is why if Dr. Randall finds evidence of infection on your pet’s skin or ears during your pet’s physical exam, she will run cytologies to determine whether the problem is a bacterial or yeast infection and prescribe appropriate medication for treatment of that infection. This is usually done during the appointment. Please be aware that cytologies and the appropriate antibiotic and/or antifungal medications (topical or oral) may add $100-200 onto the cost of the consultation but is necessary in order to treat your pets allergies or other dermatologic condition.

By submitting this form, I acknowledge the above policies and information and agree to the terms listed. *

I Acknowledge

By clicking the submit button, you agree to pay for all services at the time rendered. If your pet is covered by pet insurance, this means paying for services and then self-submitting an insurance claim for reimbursement from your insurance provider.

After hitting the submit button you should see "Form Received". If this does not happen please scroll up the form to complete any required fields you may have missed.

We look forward to meeting you and your pet soon!

New Client Form

Pet Owner Information

Patient Information

Primary Veterinarian

Food and Treats

Dermatological History

Environmental Questions

Treatments

Have a question?

Send us a message! Our team will be in touch with you shortly.

Visit us at one of our convenient locations.

Beaverton, OR

Greensboro, NC