760-568-9377 info@palmdesertvets.com

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Demographics Form

Please complete this form before your appointment

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Demographics Form

Client Information

Name *

First

Last

Spouse/Co-Owner's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Spouse/Co-Owner's Phone

Secondary Phone

Email *

Spouse/Co-Owner's Email

Patient Information

Pet's Name *

Species *

Dog
Cat

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Is your pet on heartworm prevention? *

Yes
No

Is your pet on flea/tick prevention? *

Yes
No

Add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Is your pet on heartworm prevention? *

Yes
No

Is your pet on flea/tick prevention? *

Yes
No

Add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Is your pet on heartworm prevention? *

Yes
No

Is your pet on flea/tick prevention? *

Yes
No

Previous Veterinarian and Clinic Name

How did you learn about Palm Desert Pet Hospital? (check all that apply) *

Internet/Website
Referral from a friend
Location/Sign
Yellowpages
Other

If other, please specify *

If you were referred by a friend, would you mind giving us their name so we may send them a thank you? *

May we take photos of your pet for our social media and educational purposes? *

Yes
No

I understand all payments are due at the time of service and that any balance that remains unpaid will be subject to collections and applicable fees. *

I have read and understand

Signature *

Date *

Veterinary care for the pets of Palm Desert, CA and beyond!

We know that your pet is a member of the family, and we’ll be there to make sure they are feeling their best through all stages of their life. Thank you to the amazing Palm Desert community for trusting us with your pet’s ongoing care.

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How to contact us:

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Contact Info

Phone: 760-568-9377
Email: info@palmdesertvets.com

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Location

41990 Cook St Suite B201
Palm Desert, CA 92211
Click here for directions.

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Hours

Mon - Fri: 8 AM - 5 PM
Sat - Sun: Closed

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Stop by and see us!

Send us a message!

If you need assistance, please drop us a line using the form below. If your pet needs immediate assistance, please call us directly at 760-568-9377. We look forward to speaking with you soon.

Name *

First

Last

Email *

Phone *

How may we help you? *

Website

4929673-256

Ready to come see us?

Request your next appointment online using our appointment request form. It's easy to request an appointment from any device. We look forward to seeing you soon!

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