Animal Medical Services P.C.  
             "Our family includes you and your pet."

Animal Medical Services P.C. (AMS)            T.C. Butler DVM              (812)423-2000                   www.amsvet.com

                                                              New Client Form
Thank you for giving us the opportunity to care for your pet(s). So that we may become better aquainted,
please copy this form, fill it out, and bring it with you to the office for your appointment.

CLIENT INFORMATION                                            Date ________________________

Name: _____________________________  Spouse's Name _______________________

Address ___________________________City ___________________State ______________ Zip______________

Phone ________________________ Work Phone____________________Spouse's Work phone______________

Place of Employment _________________________________ Best time to reach you ____________________

Driver's License Number * _________________________ Social Security Number* _____________________

E-Mail address ___________________________________

PAYMENT AND REFERRAL INFORMATION
All fees are due at the time services are rendered unless previous arrangements have been made. By signing at the bottom of this form you are acknowledging that you fully accept responsibility for payment of the fees incurred at AMS.

Please indicate choice of payment   ____ cash  ____ check** ____Visa
            
                                      ____ Master Card  ____ Care Credit 

How did you become aware of our clinic?    ____drove by   ___ yellow pages  ____ internet 
   ____ previous client 
   ____ current client recommended me (please list name below so that we can thank them)         
               __________________________________________________________

PET INFORMATION
(If you have more than one pet, please copy additional pages and fill out the PET INFORMATION section for each of the other pets for our records.)

Pet Name ______________________   ____Dog  ____ Cat ____other (please specify _________________________)

Breed ________________________ Date of Birth _____________________ color _____________________________

Sex     ____ male   ____neutered male  ____ female   ____spayed female.

For your dog, please list the dates that correspond to the following items in its health care program:

Rabies vaccination _________________  DHLP, Parvo Virus, Corona Virus vaccination _____________________

Bordetell vaccination __________________ fecal check for intestinal parasites ____________________________

Heartworm test and/or heartworm preventive dose ____________________________________________________

Previous medical history (list what you can recall about illnesses that you pet has suffered in the last 2 years.)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________.

For your cat, please list the dates that correspond to the following items in its health care program.

Rabies vaccination _____________________ FVRCP vaccination _____________________

Leukemia Test _____________________ Leukemia vaccination_______________________

Fecal check for intestinal parasites _______________________________.

Previous medical history (list what you can recall about illnesses that you pet has suffered in the last 2 years.)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________.

* and ** above-----The driver's license and social security information are required if you are going to pay by check. If you choose to not pay by check, do not fill in these numbers. Thank you.