Client Registration Form - Iron Mountain

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Client Registration Form robert-admin 2018-01-24T11:21:20+00:00

Welcome to Iron Mountain Animal Hospital

Thank you for giving us the opportunity to care for your pet. To help us provide the highest level of care, please take a few moments to fill out the information below as accurately as possible

CLIENT REGISTRATION FORM
Date
Name*
Spouse/Sig. Other Name
Address
Mailing Address City State / Province / Region ZIP / Postal Code
Physical Address (if different than mailing address)
Home #
Cell #
Spouses/SO Cell#
Email*
Occupation
Employer
Employer address
Employer Phone Number
Spouse’s Employer
Spouse Employer Phone Number
Preferred contact method:
- Email
- Post
- Phone (AM)
- Phone (PM)
Alternate Contact Name
Phone
Please enroll me for the hospital website newsletter:
- YES
- NO
Occasionally IMAH posts pictures of pets on our social media sites
I am interested in allowing IMAH and its agents to post pictures of my pet on their social media sites. No names will be used posting the pictures. ?
- YES
- NO
*By supplying your cell phone number, IMAH has the ability to text appointment reminders and other information relating to your pet to you. ** By supplying your e‐mail address, you authorize Iron Mountain Animal Hospital to use this address to send electronic reminders for your pets, as well as our monthly newsletter and other occasional communications we feel are necessary and important for all of our clients. Iron Mountain Animal Hospital WILL NOT supply your email address or any other contact information to ANY third party company, and know that we will do everything in our power to keep your information confidential and safe.
Would you like to receive appointment reminders via text from us?
YES
NO
How did you hear about Iron Mountain Animal Hospital?
Yellow pages
Internet search engine
Website
Recommendation
If a recommendation, whom may we thank?
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 of Owner
Date

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