Animal Hospital of Desert Hot Springs
Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health.
To insure the best care possible, please take the time to fill in this for completely. Thank you!
REGISTRATION
Date _________________________
Owner __________________________________________________________ Birthdate _______________________
Address ________________________________________________________________________________________
_______________________________________________________________________________________________
Spouse _________________________________________________________ Birthdate ________________________
Home Phone ______________________ Work Phone ___________________ Spouse Phone ____________________
Email Address ____________________________________________________________________________________
Emergency Contact _______________________________________________ Phone __________________________
How did you hear about us?
 Yellow Pages
 Recommendation
 Sign
 Other _______________________________
If recommended, by whom? ________________________________________________________________________
Reason for visit ___________________________________________________________________________________
PET HEALTH HISTORY
Name of Pet ______________________________REGISTRATION
 Dog  Cat  Other _____________________________
Breed ___________________________________ Color _________________________ Birthdate ________________
Sex
 Male  Neutered
 Female  Spayed
Vaccination History (Date and Type) __________________________________________________________________
_______________________________________________________________________________________________
Current Symptoms ________________________________________________________________________________
_______________________________________________________________________________________________
Current Medication _______________________________________________________________________________
AUTHORIZATION
REGISTRATION
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges
incurred in the care of this animal. I also understand that these charges will paid at the time of release and that a deposit may be
required for surgical treatment.
Signature of Owner _________________________________________________ Date _____________________________
Method of Payment
 Cash  Check  MasterCard  Visa  Other _________________________________
Animal Hospital of Desert Hot Springs
Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health.
To insure the best care possible, please take the time to fill in this for completely. Thank you!
REGISTRATION
Date _________________________
Owner __________________________________________________________ Birthdate _______________________
Address ________________________________________________________________________________________
_______________________________________________________________________________________________
Spouse _________________________________________________________ Birthdate ________________________
Home Phone ______________________ Work Phone ___________________ Spouse Phone ____________________
Email Address ____________________________________________________________________________________
Emergency Contact _______________________________________________ Phone __________________________
How did you hear about us?
 Yellow Pages
 Recommendation
 Sign
 Other _______________________________
If recommended, by whom? ________________________________________________________________________
Reason for visit ___________________________________________________________________________________
PET HEALTH HISTORY
Pet 1
Name
Species
Breed
Color
Sex: Male or Female
Spayed or Neutered
Birthdate
Medications
Vaccines Due?
Male
Yes
REGISTRATION
Female
No
Male
Yes
Pet 2
Female
No
Pet 3
Male
Yes
Female
No
Current Symptoms ________________________________________________________________________________
_______________________________________________________________________________________________
AUTHORIZATION
I hereby authorize the veterinarian to examine, prescribeREGISTRATION
for, or treat the above described pet. I assume responsibility for all charges
incurred in the care of this animal. I also understand that these charges will paid at the time of release and that a deposit may be
required for surgical treatment.
Signature of Owner _________________________________________________ Date _____________________________
Method of Payment
 Cash  Check  MasterCard  Visa  Other _________________________________