Client Registration Form 2024

Client Registration Form 2024
Are you 18 years of age or older?*

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

YES - CREATE ALERT ON ACCOUNTNo
Client Name*

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

First NameLast Name
Email (we send medical summaries and results via email, so it is very important to have on file!)*
example@example.com
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
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
Cell Phone Number*

Area CodePhone Number
Spouse/Significant Other Cell Phone Number

Area CodePhone Number
Landline Number

Area CodePhone Number
Which of the above phone numbers is your PRIMARY contact number?

My Cell Phone NumberSignificant Other's Cell Phone NumberLandline Number
Employer
Employer Phone Number

Area CodePhone Number
Emergency Contact
Emergency Contact Phone Number

Area CodePhone Number
Occasionally IMAH posts pictures of pets on our social media sites. Check whether you are interested in allowing IMAH to post pictures of your pet on our social media sites. No names will be used when posting the pictures.*

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*

Clear
Date*

MonthDayYear
Date
Should be Empty: