contact us

Use the form on the right to contact us.

You can edit the text in this area, and change where the contact form on the right submits to, by entering edit mode using the modes on the bottom right.

5175 Pacific St., Ste B
Rocklin, CA 95677
USA

(916) 632-2400

Client/Patient Form

Please fill out this form as accurately and completely as possible.  This information will help us prepare for your visit so the doctor can spend as much time as possible with you and your pet.

Personal Information
Client Name *
Client Name
Second Owner Name
Second Owner Name
Client Address *
Client Address
Primary Phone *
Primary Phone
Secondary Phone
Secondary Phone
Veterinary Information
Referring Veterinarian Phone
Referring Veterinarian Phone
Referring Veterinarian Fax
Referring Veterinarian Fax
Patient Information
Species *
Gender *
Date of Birth *
Date of Birth
Please provide us with a brief description of your pet's problem. When did it start? How has the problem progressed? What areas are affected? Is your pet itchy? Etc.
Please list all medications (including dosages) that your pet is currently taking.
Please list product name and how often used.
Please list product name and how often used.
Please tell us what brand(s) and flavor(s) of food your pet eats.
Do you give Animal Dermatology & Allergy permission to take photos of your pet and use these images for the purposes of medical records, continuing education, teaching, and awareness, including educational lecture presentations and social media? *
Photography Permission