Client name ______________________________________________________________________
Pet ______________ Age ____ Sex _____ Breed _________ Description _____________________
I do hereby certify I am the owner (or duly authorized agent for the owner) of the animal described, and I do hereby give the doctor, her agents, employees and representatives authority to perform a physical examination, to recommend and prescribe treatment options including complementary therapies such as, but not limited to acupuncture, chiropractic, homeopathic and herbal medicine. I understand I will have the opportunity to accept or decline treatment recommendations verbally at the time of examination. I understand that many of the treatments utilized in this practice are beyond the scope of traditional veterinary medical options, and are not considered standard of care in the veterinary industry. I further understand that no guarantee of outcome can be made about this or any other treatment option presented. I take full responsibility for the treatment options I accept for my pet, and I will not hold the doctors or the practice responsible for results or complications that might arise due to the treatments.
The purpose of this initial visit is to evaluate my pet for the following problems; ___________________ __________________________________________________________________________________
and to discuss a treatment program that may be useful to promote resolution of the symptoms listed, and/or to promote the overall health of the above described pet. This release will automatically serve as a release for any future examinations and/or treatments if I schedule additional appointments.
I accept full responsibility for the fees generated by services I authorize. I understand all fees are due and payable at time of service, or at the time the animal is released from the hospital. Any exception to this policy must be authorized prior to the performance of any service. We accept cash, checks, Master Card and Visa, American Express, and Discover for your convenience.
Client signature _____________________________________________ Date ________________
__________ I have full authority to make medical & financial decisions regarding the treatment of this pet.
If not; __________________________________ should be contacted at; ph# ________________
Questions? ___________________ _______initial