Client Registration Form 2025

Client Name*

First NameLast Name

Cell Phone Number*

Area CodePhone Number

Primary Contact Email Address*

example@example.com

Spouse/Significant Other Name (if none, write "none" in both fields)*

First NameLast Name

Spouse/Significant Other Cell Phone Number

Area CodePhone Number

Spouse/Significant Other Email Address

example@example.com

Landline Number

Area CodePhone Number

Which phone number above is the PREFERRED contact number?*

Primary Contact Cell NumberSpouse/Significant Other Cell NumberLandline

Which email is the PREFERRED email for the account?*

Primary Contact Email AddressSpouse/Significant Other Email Address

The "preferred" selections will receive medical summaries, invoices, appointment reminders, and texts.

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physical Address (if different from mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Alternate Contact (Other than those listed above)

Alternate Contact Phone Number

Area CodePhone Number

We send out vaccine/health reminders via text and email. If you REQUIRE a postcard reminder because you do not have access to text OR email, please select this box.

I require postal reminders

Occasionally IMAH posts pictures of pets on our social media sites. Would you like your pet featured?*

YesNo

If another vet clinic contacts us, do we have your permission to share your pets' medical records with them? (If you select No, we will text you each time we are asked for these records).*

YesNo

If a shelter, rescue, groomer or boarder contacts us for vaccine history for your current pets, do we have your permission to share them? (If you select No, we will text you each time we are asked for these records).*

YesNo

Do you or any members of your household have a peanut allergy? (We use peanut butter as treats!)*

YES - CREATE ALERT ON ACCOUNTNo

Are you 18 years of age or older?*

YesNo

To allow us to maintain our high standards of veterinary medicine, full payment is required at the time of service.

MEDICAL AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe, and treat my animals under your care. I assume responsibilities for all charges incurred by the care of my pet, and understand that these charges will be paid in full at the time services are rendered. I also understand a deposit may be required for any surgical treatment.

Signature*

Date*

Date