New Client Form

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client Form

Name (required)
First Name (required)	Last Name (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

Pet's Name (required)

Species (required) :

If "other" indicated above, please list species.

Breed and Color

Sex ( Male M / Female F / Neutered male NM / Spayed female FS)

My pet's vaccinations are up to date.

I will have a copy of my pet's medical record.

I will call my former veterinarian and request records be faxed to Dr. Butler.

(Our fax number at AMS is 812-423-2645)

I would like for an AMS representative call me to set up an appointment.

Reason for your coming appointment.

Please list additional pets here. (Name, Species, age, sex)

Who can we thank for refering you to AMS?

Please read the following:
I understand, by indicating "I agree" below and submitting this registration, that I am responsible for any charges incurred during the treatment of my pet while under the care of Dr. Butler and the staff at ANIMAL MEDICAL SERVICES P.C. I further agree that those 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 thirty (30) days will accrue a monthly finance charge of 2.0% per month (24% per annum) OR $5.00 (whichever is the greater). Any balance that I leave unpaid will be forwarded to Animal Medical Services' collection agency, and will incur a 33% collection fee for which I am also liable, in addition to any and all finance charges stated above.

I agree to abide by the above stated AMS finance policy.

Please feel free to utilize the space below for questions or comments.

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