Dermatology rDVM Questionnaire Form

U of MN Veterinary Medical Center
Dermatology Service Telephone: 612-624-4831 email: vetderm@umn.edu Please assist us by completing the requested information.

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



CLIENT & PATIENT INFORMATION

RDVM INFORMATION



REASON FOR VISIT & EXPECTATIONS




PART I: CLINICAL INFORMATION


Upon form submission, you will be redirected to a page that will allow you to upload images. You should also receive a link in your email that will provide information for uploading images for this patient.


PART I: CLINICAL INFORMATION & TEST SUBMISSIONS
Please check each checkbox and fill in the information for the findings requested for each test performed.


  

  

  

  

  

  
After submitting the form you will be redirected to a page which will allow you to attach a copy of the histopathology results.


  


If yes, when:


If yes, diet used:
If yes, duration of trial:
If yes, response:

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PART II: PREVIOUS TREATMENTS
Please list drug names, dosages, frequency of administration & check a response for each medication.

ex.
1.
2.
3.
4.
5.

PART III: CURRENT TREATMENTS
Please list drug names, dosages, frequency of administration & check a response for each medication.

ex.
1.
2.
3.
4.
5.

PART IV: ADDITIONAL INFORMATION






Please enter the last 4-digits of the VMC main phone number 612-626-8387: