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) *

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

I hereby authorize the Palm Desert Pet Hospital to perform such diagnostic, therapeutic, and surgical procedures as are necessary and advisable for treatment and maintenance of my pet’s health and well-being. *

I have read and understand

I will expect all procedures to be done to the best of the abilities of the veterinarian and hospital staff, I realize that there is no guarantee nor warranty can ethically or professionally be made regarding the results or cure. *

I have read and understand

I also authorize the hospital veterinarian and hospital staff to provide veterinary services as requested or in emergency circumstances to follow through with such procedures as are necessary for the well-being of my pet. *

I have read and understand

I understand that payment is due in full at the time that services are performed. If admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Cash, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. I understand that the card holder must be present when using any type of credit or debit card. *