Day Admission

Name: Lane Animal Hospital
Address: 701 N Main St, Chelsea, MI, 48118, United States
Telephone: 734-475-8696
Price range: $

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Day Admission Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 734-475-8696 for a faster response.

Name *

First

Last

Phone Number *

Email *

Pet's Name *

Reason for Drop-off Appointment *

If for an illness, how long have these symptoms been occurring? *

Is your pet having any coughing/sneezing/vomiting or diarrhea? *

Any exposures or ingestion of foreign objects?

Any change in diet or treats?

What kind of diet do you feed? Please list type, amount, frequency and when they last ate. *

Is your pet having normal urination/defecation? *

If your pet is a cat, does it ever go outside?

Please list all current medications, dosage and frequency and when last given. (medications also include, preventatives, vitamins and supplements) *

Are there any other services or medication refills you would like from us today?

While in our care should anything life threatening occur with your pet, would you like us to perform CPR? *

Approved
Declined

Please select from the following *

I approve any diagnostics, not to exceed $200 without first receiving a phone call for approval
I approve any and all diagnostics that my veterinarian deems warranted. Prior approval not required
I do not approve any diagnostics other than the physical exam ($46) without first receiving a phone call and medical care treatment plan outlining costs. I understand that if I do not answer my phone at the number provided, my pet will NOT receive care and my appointment may need to be rescheduled for a later time.

**Please note the physical exam fee is $75 if your pet is scheduled to be dropped off urgently

The nature of such service has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically or professionally be made regarding the cure or result. I further recognize that there is an inherent risk of adverse reaction to any medication, including anesthetics, and vaccination that may be administered to my pet.

I understand that I assume financial responsibility for all services rendered, and that payment is due at the time the animal is released. A finance charge of 1.5% per month will be computed on all unpaid balances over 30 days. A fee of 33-1/3% will be assessed to all accounts that require outside collection services.

Signature *

Day Admission

Day Admission Form

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