"*" indicates required fields Day Admissions are for the convenience of our clients! We know schedules don’t always align but it’s important to have your pet seen in a timely manner. We offer a Day Admission that may be the right solution for you. How it works: Call our practice to get scheduled for a check-in time for your pet Check in with our staff upon drop off Your pet will remain in a comfortable space until our veterinarian has time in the schedule to do their examination and read over your Day Admissions Form. Once the exam is complete the doctor or staff member will contact you with findings or recommendations for diagnostics and/or treatment During the call - together a treatment plan will be agreed upon and approved. Estimates can be provided at this time. Services will be performed and your pet will be ready for pick up at the discharge timePlease expect discharge to take about 15 minutes. At this time the Doctor or staff member will have a follow up discussion regarding the services provided, cover any at home instructions and/or when to expect diagnostics results. Please complete the following form to allow for your pet’s Day Admission to our practice. We ask that you explain in detail the reason for the admission and any concerns you may have. Please note a signature of anauthorized agent and emergency phone are required.Owner’s InformationName* First Last Phone*Pet’s InformationName* Age* Breed* Reason for your pet’s visit:*How long have your pet’s symptoms been going on?* Have the symptoms been worsening/ staying the same?* Are these symptoms new or reoccurring?* Have you recently changed your pet’s diet or introduced new foods?* Does your pet ever eat things he/she shouldn’t?* Could it be possible your pet ingested something without you knowing?* When was your pet’s last meal? What medications (if any) has your pet received in the last 24 hours?NameAmountTime Given Add RemoveAll pets admitted to our practice must be current on their Rabies Vaccination for the safety of our staff. Is your pet’s vaccination current? Yes, my pet is current No, my pet is not current Please choose one option below to help us efficiently care for your pet in a timely manner. PLEASE NOTE: Once admitted to the practice- a $60.00 Medical Exam Fee will be applied to your invoiceI AM authorizing the veterinarian to perform all services he/she deems necessary, in the event I can not be reached at the time of calling to discuss a treatment plan. I understand this may or may not include lab testing, x-rays or use of sedation. I AM authorizing the veterinarian to perform all services he/she deems necessary, in the event I can not be reached at the time of calling to discuss a treatment plan. I understand this may or may not include lab testing, x-rays or use of sedation. I authorize up to $My authorization is required regarding additional costs before proceeding.I AM authorizing the veterinarian to perform all services he/she deems necessary, in the event I can not be reached at the time of calling to discuss a treatment plan NOT INCLUDING sedation of my pet. I AM authorizing the veterinarian to perform all services he/she deems necessary, in the event I can not be reached at the time of calling to discuss a treatment plan NOT INCLUDING sedation of my pet. I authorize up to $My authorization is required regarding additional costs before proceeding.I AM NOT authorizing any services to be performed other than the necessary Medical Exam without specific authorization. I understand if I can not be reached at the time of calling to discuss a treatment plan, services will be delayed and may result in returning to the practice for approved services I AM NOT authorizing any services to be performed other than the necessary Medical Exam without specific authorization. I understand if I can not be reached at the time of calling to discuss a treatment plan, services will be delayed and may result in returning to the practice for approved services Please read each of the following and acknowledge each statement.Payment for Services* Payment for Services * An estimate will be provided to me upon my request. A deposit may be required prior to services being rendered I understand I am responsible for all charges incurred and payment is due upon release of my pet. I understand the medical exam performed on my pet once admitted to the hospital is a $60.00 fee that is already an incurred charge Hospital Policies* Hospital Policies * Any pets staying in the hospital, for any reason, are required to be free of fleas, ticks, or any other external parasites. If the staff finds any parasites on your pet, we will administer parasite control at the owner’s expense. Our practice is to use all reasonable precautions against injury, escape, or demise but will not be held liable or responsible in any manner regarding the care, treatment or safe keeping of the animal. I understand that I am assuming risks involved in care and treatment for this animal. Sedation / Anesthesia* Sedation / Anesthesia * Every effort is made by our practice to ensure the safety of the medical procedure when using sedation/anesthesia. I acknowledge there are always risks involved and the possibility of complications in any procedure. In the event of my pet should go into cardiac/ respiratory arrest (heart stops/ stops breathing) CPR or DNR* CPR - I give permission for American Veterinary Hospital to perform CPR and other lifesaving measures. DNR - I do not wish for any lifesaving measures to be taken. During the day, it is important that our hospital is able to immediately reach the owner/ authorized agent responsible for making both health care and financial decisions. The undersigned is that agent. In admitting my pet(s) for diagnostics, treatment, or procedures, I hereby consent and authorize American Veterinary Hospital to receive, treat and prescribe as deemed necessary. Agent's Signature*Date* MM slash DD slash YYYY Phone*EmailThis field is for validation purposes and should be left unchanged.
