New Client Form

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We love new clients and patients! Please complete the form below before their first visit. If you need immediate assistance, please call our team directly at 217-324-3311.

Owner's Name *

First

Last

Owner's Email *

Owner's Home Phone *

Owner's Mobile Phone

Owner's Employer

Owner's Work Phone

Owner's Address

Address Line 1

Address Line 2

City

State

Zip Code

Owner's Driver's License # and Exp. Date

Co-Owner's Name

First

Last

Co-Owner's Email

Co-Owner's Phone

Co-Owner's Employer

Co-Owner's Work Phone

Co-Owner's Driver's License # and Exp. Date

All fees are due and payable upon completion of services. I further agree to pay all costs incurred to collect overdue accounts, including collection agency charges, attorney's fees, court costs, and any other charges allowed by law. *

I have read and understand.

At times, we may take pictures of your pets to use on our Facebook and Instagram. Only patient names will be linked to these pictures. No last names will be used. In order to do this we need your consent. If you would like to give us permission to do this, please mark the appropriate box below. *

Yes, I give the staff of AMC permission to take and use pictures of my animals on any social media sites that are associated with or run by the AMC
No, I do not give the staff at AMC permission to take and use pictures of my animals on any social media sites that are associated with or run by AMC.

How did you hear about us? Did someone refer you to us? If yes, please let us know who.

Digital Signature *

Today's Date *

Pet #1 - Please include: Name, breed, color, age/date of birth, sex, have they been spayed or neutered, special information we should know, previous health concerns, and any information on allergies or reactions.

Pet #2 - Please include: Name, breed, color, age/date of birth, sex, have they been spayed or neutered, special information we should know, previous health concerns, and any information on allergies or reactions.

Pet #3 - Please include: Name, breed, color, age/date of birth, sex, have they been spayed or neutered, special information we should know, previous health concerns, and any information on allergies or reactions.

Pet #4 - Please include: Name, breed, color, age/date of birth, sex, have they been spayed or neutered, special information we should know, previous health concerns, and any information on allergies or reactions.

Pet #5 - Please include: Name, breed, color, age/date of birth, sex, have they been spayed or neutered, special information we should know, previous health concerns, and any information on allergies or reactions.

Signature *

Clear Signature

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