New Client Form

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

Please fill out our New Client Form prior to your appointment. We kindly ask that you answer all questions if possible and provide as much detail as you can. Thank you! We look forward to meeting your family. If you have any questions, please call us directly at (503) 574-4150.

Which clinic will you be visiting? *

Beaverton, OR
Kernersville, NC

Have you scheduled an appointment yet? *

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/Landline *

Secondary Phone

Cell/Landline

Work Phone Number

Cell/Landline

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? *

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?

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?

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)

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

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?

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?

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.).

Please describe. *

Treatments

Is your pet being given any medications or supplements for allergies or another medical condition? *

Please list the medication(s). *

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!

Phone

Have a question?

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

Name *

First

Last

Email *

Phone

How can we help you? *

Name

Visit us at one of our convenient locations.

Beaverton, OR

13025 SW Millikan Way Suite 100
Beaverton, OR 97005

M, Tu, Th, Fri: 8am - 6pm
Closed Wednesday

Greensboro, NC

Coming in 2023

Kernersville, NC

719 Gralin St.
Kernersville, NC 27284

Tues-Friday: 8am - 6pm
Sat-Sun: 9am - 6pm