New Client Form

New clients, please also complete the New Patient, small animal, or Equine form and contact the office to schedule an appointment.

717-529-0526

If you prefer to print this form, download the PDF here.

New Client Information

Today's Date:*
MM slash DD slash YYYY
Is this your first appointment at Always Helpful?*
- Yes
- No
If No, when was your last appointment?
MM slash DD slash YYYY
Referred By:
Client Information*
First Name Last Name
What do you prefer to be called:
Gender
- Male
- Female
Date of Birth:
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Home Phone:*
Home Fax:
Work Phone:
Cell Phone:*
Other Phone1:
Email Address:
Website Address:
Any phone preferences or prohibitions (i.e. - best time to call, whom to leave messages with (or not), etc.)
Name & phone number of person to call in case of emergency (for you or the animal):
Confirmations & reminders sent
- Phone
- Email
- Text
Occupation:
Special Interests:
Are you a patient or client of a chiropractor, acupuncturist, therapist, healer, or helper? Describe.
Do you own any in-home medical therapy devices? If yes, what is the name and brand of the device(s) and how is it used?
The following information is optional but may be extremely important in regard to your animal's health.

List or describe any major issues for you or your animal's multi-species "family" in the following areas.
Health:
Emotional:
Family:
Environmental:
Any other information you would like us to have:
Cancellation fee will apply if not given 24 hours notice (Lg./ $100, Sm./ $25).

Applies to:

All clients of Always Helpful Veterinary Services and participants of any Maximum Horse Power event. My signature below confirms that the conditions of my consent to be video-recorded/photographed have been explained to me, and I understand the following:
- I am not required to be video-recorded/photographed.
- I can withdraw my consent at any time by submitting a written request to the practice manager.
- The recordings are for educational/advertising purposes &/or placed on our website and/or social media Page. My name and image will not be used for any other purpose.
- I will receive no compensation for my consent to participate in the recordings.
- Others will review the recordings/photos as an educational opportunity to improve client and patient care. Identity of you and your animal are to be kept confidential unless you choose to be identified as part of a testimonial.
Please initial if you agree to be identified.
I relinquish any right to the recordings/photos and understand the DVDs/videotapes/photographs may be copied and used by Always Helpful Veterinary Services &/or Maximum Horse Power, without further permission.

I hereby release Always Helpful Veterinary Services &/or Maximum Horse Power, and any of its associated or affiliated companies, their directors, officers, agents, employees, and customers, and appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind on account of such use.
If participant is under age 18, Name:
I,*
, am the parent/legal guardian of the individual named above; I have read this release and approve of its terms. I agree to raise any concerns or areas of discomfort with the office manager. The original copy of this consent form will be kept in my records.
Print name:*
Date*
MM slash DD slash YYYY
Signature*
Pets Name:*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

New clients, please also complete the New Patient, small animal, or Equine form and contact the office to schedule an appointment.

717-529-0526

New Client Information

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