Acupuncture Consent Form at Rutherford Veterinary Hospital

Acupuncture Consent Form

Informed Consent For Alternative or Complementary Veterinary Medical Treatment

Owner's Name
Owner's Name
First
Last

Animal identification

PLANNED PROCEDURE/TREATMENTS:

May include any or all of the following

a) Acupuncture –including dry needling, acupuncture, and acupressure. b) Herbal Therapy c) Nutritional or Food therapies d) Massage or Physical Rehabilitation

AUTHORIZATION:

1. I am the owner / agent of the owner of the animal(s) identified above. I am 18 years of age or older, and I have the authority to give this consent.

2. I have been advised by Dr(s)._____ of both the conventional/traditional veterinary methods and treatments along with the complementary or alternative veterinary procedures/treatments identified above. There procedures/treatments have been explained to my satisfaction including the purpose for performing them, the potential benefits, the risks involved, costs, prognosis, and the likely consequences of having no treatment or using only complementary and alternative veterinary medicine.

3. I am aware that the above mentioned complementary or alternative modalities to be used in the treatment of my animal are not considered conventional veterinary medicine. 4. I hereby authorize the performance of the above-identified procedures/treatments and the use of any associated medications either conventional or complementary by Dr. Rowan or her auxiliary in her practice of Veterinary Medicine. 5. I understand that there can be no guarantee as to the animal’s condition or outcome of any procedure or treatment undertaken. 6. I have read and fully understand this form and declare that I voluntarily provide my informed consent as per the above items.