Day Admit Form
Chisholm Trail Pet Clinic offers Day Admit appointments for those pet owners whose schedules are
hectic and are unable to make a regular appointment.
Your pet may be admitted for veterinary services as early as 7:30am and discharged by 5:15pm,
Monday, Tuesday, Thursday, and Friday (1:45pm on Saturdays).
We may also offer your pet(s) a Day Admit appointment if our schedule is tight and no regular
appointment with a veterinarian is available the date you are requesting.
Prior arrangement is required. Please call and speak with a staff member to make a Day Admit
appointment. Complete and bring this form along with your pet(s).
Presenting Complaint / Concern:
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History:
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Vaccination Status:
Current: _____
Not Current: _____
If not current and the patient's health status will allow, do you want your pet to receive vaccinations
and routine health testing?
Canine
Rabies _____
DHPP-CCV / DHLPP / DAP _____
Lymes _____
Bordetella _____
Crotalus Atrox Toxoid _____
Fecal _____
OHWC/Lymes/Ehrlichia _____
Feline
Rabies ______
FVRCP / HCP _____
FeLV _____
Fecal ______
FeLV/FIV testing _____
Parasite Control:
All animals admitted to the clinic must be free of parasites, including fleas, ticks, mites, and
intestinal parasites. If your pet(s) is found to be infested with parasites, he will be treated
according. You will be financial responsible for this service.
Procedure Authorization:
If the veterinarian determines that diagnostic lab work is indicated, may we proceed?
Yes _____ No _____ Call for approval _____
If the veterinarian determines that radiographs (x-rays) are indicated, may we proceed?
Yes _____ No _____ Call for approval _____
Cost of Service – Treatment Plan:
Is an estimate needed? Yes _____ No _____
For any amount? _____ For $0.00 to $150.00? _____ For $151.00 to $250.00? _____
For $251.00 to $350.00? _____ For $351.00 to $450.00? _____ For $450.00 or greater? _____
Discharge:
What is the earliest time today that you will be able to retrieve your pet? __________________
What time would be the most convenient time for you to retrieve your pet? ________________
Contact Information:
What number(s) will you, or an authorized agent of yours, be available to answer any questions that
we may have concerning your pet today?
Name: _____________________________________________
Numbers: __________________________________________
___________________________________________
As owner, or duly authorized agent of the owner, of the above named animal, I hereby consent and
authorize the clinic staff to receive, vaccinate, perform diagnostics, treat, perform surgery, and/or prescribe
as needed for this animal. I understand that I am assuming all risks involved in the care and treatment of this
animal. I consent to the administration of sedation / anesthesia as deemed necessary by the doctor. I
acknowledge that risks and the possibility of complications exist in any surgical or medical treatment.
An estimate of anticipated fees has or will be given to me on my request.
All charges shall be paid in full upon release of my pet.
SIGNATURE: __________________________________________
DATE: _______________