Animal Hospice of Mid-Michigan

Animal Hospice of Mid-Michigan
Animal Hospice of Mid-Michigan - New Client Forms
Date*

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Date
Client's Name*
Spouse/Others Name*
Animal's Name*
Address*
Apt/Suite Number
City*
State*
Zip*
Primary Phone Number*
Secondary Phone Number
Spouse's Phone Number
E Mail Address*
example@example.com
Employer's Name
Approved name/phone number for medical release of info
Social Security Number: We require either a SS number or DI number to be on file. We do not share your information with any other individual
Social Security Number
Driver's License Number
Professional fees are due before services are rendered at time of scheduling. We do not bill.

We accept VISA/MC/AMEX/DISCOVER.
How did you hear about our hospital?
I certify that the above information is true to the best of my knowledge. I understand that full payment is due at the time services are scheduled. I also understand that if my account should become delinquent for any reason, I will be charged an 18% annual percentage rate, or a minimum of $2.00 billing fee per month, whichever is greater. There is a $50.00 service fee for all no call/no show appointments that are booked in-person.
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Animal Hospice of Mid-Michigan
Animal Hospice of Mid-Michigan - Patient Information
Name*
Age*
Sex*
Spayed/Neutered?*
Species*
Breed*
Color*
Primary Care Veterinarian*
Ph Number*
Do we have permission to contact your veterinarian for medical records?*
Veterinary records from your primary vet are REQUIRED before services can be offered. If your animal does not have a primary care veterinarian, or has not been to the veterinarian in several years, it is likely that we will not be able to offer end-of-life services.
Medical Conditions
Is your pet currently on any medications? If so, what medication and what dose?
Reason for inquiring about services*
I understand that an examination must be done on my pet before services are scheduled, including euthanasia services. This examination can be done in my home or at the veterinary facility. Examinations/services performed in my home are subject to travel fees. Services are offered Monday-Friday during regular business hours. Scheduling is typically done 5-7 days in advance and is not always available immediately. Emergency fees may apply for services rendered outside of regular business hours. I also understand that the DVM reserves the right to refuse to cuthanize a patient that they do not feel is terminally ill, in which I would still be responsible for travel and professional time charges.
Signature*

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Date*

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Date
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