Client Registration Form 2021

Client Registration Form 2021
Are you 18 years of age or older? *

Yes No
Do you or any members of your household have a peanut allergy? *

YES - CREATE ALERT ON ACCOUNT No
Client Name *

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

First Name Last 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

City State / Province

Postal / Zip Code
Physical Address (if different from mailing address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Spouse/Significant Other Cell Phone Number

Area Code Phone Number
Landline Number

Area Code Phone Number
Employer
Employer Phone Number

Area Code Phone Number
Emergency Contact
Emergency Contact Phone Number

Area Code Phone 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. *

Yes No
How did you hear about Iron Mountain Animal Hospital?

Recommendation Google/Internet Search Facebook or other online community group Yellow Pages
If a recommendation, whom may we thank?
Name of person who gave the recommendation
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 uner 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 sugical treatment.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm