Lawrence Veterinary Hospital

3210 Clinton Parkway Ct.
Lawrence, KS 66047

(785)841-9956

lawrencevethospital.com

NEW CLIENT REGISTRATION

You can assist us to expedite your check in after you have scheduled your appointment, by submitting this form. You can make future appointments via the "My Petly" icon to the right.

Thank you for choosing Lawrence Veterinary Hospital!

James Kraft, DVM
Anna Johnson, DVM
and the staff at Lawrence Veterinary Hospital

New Client Registration

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 (required)

Cell phone (required)
Phone TypePhone Number (required)
Alternate Phone

E-Mail Address (required) :
Confirm E-Mail Address (required) :
How may we contact you regarding your pet(s) healthcare? Phone, email, text (required)
opt out
opt in email and text
opt in email
opt in text
contact by regular mail


Your Pet
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered (male)
Spayed (female)


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


Do you have Pet Insurance?
Yes
No
I would like more information


Reasons or conditions that prompted your visit?

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

Why did you select our hospital?
Location
Online Reviews
Our Website


May we contact your former veterinarian for your pets 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

________________
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. We accept payment in cash, check (with ID), American Express, Visa, MasterCard, Discover, and Care Credit, credit cards.
I have read this statement and - (required)
I Agree
I Disagree



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