Client Information

Date

Name *

First

Last

Mr.
Mrs.
Ms.
Other

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Significant Others Name:

Significant other's cell

E-mail Address *

Lifelong Pet Health Care use only for vaccine/medical records, lab results, imaging results, and reports.

D.L. #

State

Whom may we thank for referring you?

Employer

Occupation

Besides yourself, in case of emergency, who should we contact?

Phone

Pet Information

Pet’s Name

Sex:

Birthdate

Age

Breed

Species:

Canine
Feline

Describe the reason for your pet’s visit

Please fax/email vaccines and medical history prior to the visit, if applicable. Fax: 785-267-2575 or lifelongpetstaff@gmail.com

Payment Policy

We will gladly prepare a written estimate if you desire (please ask our doctor or receptionist). ALL PROFESSIONAL FEES
ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures where
full payment may be difficult at discharge, we accept major credit cards. In-clinic care credit application processing (2 forms
ID required), with results in minutes.

To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines and free from all internal and external parasites. The signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice.

Signature of Client Responsible for Pet(s)

Clear Signature

Date

I will be paying with

Cash
AMEX/Discover
Visa/MasterCard
Care Credit

Welcome

New Patient Form

New Patient Form

Client Information

Pet Information

Payment Policy

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Questions?

Location

Contact Information

Hours

Areas We Serve