785-841-9956


New Client Check In

After you have called for an appointment, you can assist us to expedite your check in by submitting this form.

Thank you!

Form - New Client

Your Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Apartment #

Employer (required)

Drivers License Number and State

Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
Cell Phone
Phone TypePhone Number
E-Mail Address :
Confirm E-Mail Address :
Other Contact
First Name
Last Name
Other Contact Address
Street Address
City
State/Province
Zip/Postal Code
,
Other Contact Phone
Phone TypePhone Number
Your Pet
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current? (required)
Yes
No
I don't know

Reasons or conditions that prompted your visit?

Are your pets taking any medications at this time (please list)?

Do you have your pets' medical records, or are they at another veterinary practice?
Yes
No
At another practice

May we request a transfer of records?
Yes
No

Name of Former Veterinary Practice

Address of former Veterinary Practice
Street Address
City
State/Province
Zip/Postal Code
,
Phone of former Veterinary Practice if known
Phone TypePhone Number
YES, please call me for an appointment
Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Lawrence Veterinary Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Lawrence Veterinary Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and - (required)
I Agree
I Disagree


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