Pre-Screen My Dog

"*" indicates required fields

Thank you for your interest in this free clinical study for dogs with specific ear problems.

Please complete this brief form to help us determine if your dog may qualify for screening. The form is estimated to take no more than 5 minutes to complete. *All questions require a response.

If you have more than one dog that you believe may qualify, please complete a separate form for each.

Participating study sites are located in the following cities; please select the nearest location to you:*

We’re sorry, it appears that there’s not a participating site in your area. If your dog continues to have ear problems, please reach out to your own veterinarian or check back later as new locations may be added in the future. Thank you for your interest.

Date: 05/31/2023

About Your Dog

1. Dog’s Name:*

2. Is your dog at least 4 months of age?*

Yes

We're sorry, but dogs must be at least 4 months of age to participate in this study. Thank you so much for your interest.

3. Has your dog participated in another clinical study in the last 3 months?*

Yes

We’re sorry, dogs may not have participated in another study in the previous 3 months. Thank you so much for your interest.

4. Are you able to bring your dog into the clinic for study visits?*

Yes

We’re sorry, but dogs must come to the veterinary clinic for this study. Thank you so much for your interest.

5. What signs of ear problems are you currently seeing with your dog? (Check all that apply)*

Head shaking

Itchiness, scratching

Rubbing on furniture, or rolling on floor or ground

Redness in or on the ear(s)

Unusual odor in one or both ears

Swollen or puffy ear flaps

Crusty skin or scabs on ear(s)

Other signs (Write in):

Other*

We’re sorry, dogs that have this ear condition are not eligible for this study. We encourage you to reach out to your own veterinarian to have your dog’s ears checked. Thank you so much for your interest.

Your Dog's Ear Treatment History

1. Has your dog had ear problems in the past 12 months?*

Yes

Approximately how many times?*

1 to 3

4 to 5

More than 5

2. Have you used anything in your dog’s ears (including washes or treatments) in the past 2 weeks?*

Yes

Your Dog's Medical History

1. Please indicate any medical conditions your dog has experienced:*

Other (Write in):

2. Please choose the timeframe that best represents when your dog last received a medication or supplement in the following categories. Or choose "None" if your dog has not received any in the category. (Select all that apply)

Flea/tick medication [Such as Frontline®, Bravecto® (fluralaner), Advantix®, sprays, or collars]*

Pain medication [Such as Rimadyl® (carprofen), Deramaxx® (deracoxib), Metacam® (meloxicam), gabapentin, tramadol]*

Anxiety medication [Such as fluoxetine, trazadone]*

Oral allergy medication [Such as Benadryl® (diphenhydramine HCL), Zyrtec® (cetirizine HCL), Apoquel® (oclacitinib)]*

Injectable allergy medication [Such as Cytopoint®]*

Antibiotic*

Steroid [Such as prednisone]*

Glucosamine or similar joint supplement*

Fish oil*

Allergen-specific immunotherapry [i.e. “allergy shots”]*

Other (write in):

Your Dog's Veterinarian

1. Does your dog receive veterinary care?*

Yes

Prefer not to answer

1b. Clinic Name:*

Address*

City State

About You

It appears your dog may be eligible for screening for this study. Importantly, please do NOT clean your dog’s ears before coming in for screening.

If you wish to continue, please fill in the following so that we may contact you. (We will NOT use your info for any other purpose, nor will it be shared with anyone outside the study.)

Name*

First Last

City, State, Zip*

City State ZIP Code

Phone*

Email*

How did you learn about this study? (Check all that apply)*

Facebook

Instagram

Saw an ad on a website I visited

Internet search

Friend

My veterinarian

Other (Write in):

Other (write in):*

Please prove you are human by selecting the plane.

This field is for validation purposes and should be left unchanged.