Animal Medical Services
Our family includes you and your pet.
 
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Questions?   email us at info@amsvet.com

New Patient Form/Request for Information

If you would like to make an appointment, you can speed up the check-in process by submitting this form. This form can also be used to submit questions for our staff by filling in the required fields and skipping to the last field to enter your question.

Thank you for your cooperation in allowing us to assist you. 

New Client/Information Form

First and last name:
Co-owner's first and last names:


Street Address:
City and State: Zip:  
 
   
Home Phone (with area code):
Work Phone (with area code):
Cell Phone (with area code):
E-mail Address:


Pet Information

Pet Name:
Type of Pet:
Breed:
Color:


Sex:
Spayed/Neutered:

Date of Birth:

Are Pets Vaccines Current?  Yes NoNot Sure

Do you have pets medical records?  Yes No

Second Pet:

Type of Pet:
Breed:
Color:


Sex:
Spayed/Neutered:

Date of Birth:


Are Pets Vaccines Current?  Yes NoNot Sure

Do you have pets medical records?  Yes No

Third Pet:

Type of Pet:
Breed:
Color:



Sex:
Spayed/Neutered:

Date of Birth:

Are Pets Vaccines Current?  Yes NoNot Sure

Do you have pets medical records?  Yes No

Are there medical records for your pet(s) at another Veterinary Practice?

Yes    No

May we contact them?

Yes    No

Name of former Veterinary Practice?

How did you find our website?

Internet Google Search     Internet Name Search

Business Card                  Brochure

Dr. Referral,  (If so, who?:)  

Friend or other Source (Please specify: )

Please read the following and respond (for new clients only- not applicable if you are submitting a question or seeking information.)

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 Animal Medical Services, 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 2.0% or 24% per annum. Any balance that I leave unpaid will be forwarded to Animal Medical Services collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement andI agree
I do not agree
.


If there is anything else you would like to tell us, please enter your comments here:

 



Animal Medical Services P.C.
2918 Mt. Vernon Avenue
Evansville, IN 47712
Phone: 812-423-2000
Fax: 812-423-2645

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