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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. |
812-423-2000
Animal Medical Services P.C.
"Our family includes you and your pet."
For Veterinary Medicine, Surgery, Dentistry, Boarding and Grooming.
2918 Mt. Vernon Avenue, Evansville, IN 47712
