Owner Name: *

First Name

Last Name

Phone: *

(###)

###

####

Address: *

Please let our office know if this address can also be used for shipping purposes for medications/herbs/supplements.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Veterinarian Phone:

(###)

###

####

Are you willing to bring your dog to our home office in San Gregorio for treatments? *

Yes

No

May we have your permission to obtain your pet's records from your referring veterinarian?

Yes

No

We want to work with your regular veterinarian as a team. As such, would you like us to send our records back to your regular veterinarian?

Yes

No

Does your pet have any temperature preference?

No temperature preference

Prefers to be in the sun/near the heater/fire

Prefers to be in the shade/on cool floors

Other

How does your pet drink water?

Large amounts, few times a day

Small amounts , frequently throughout the day

Average amounts, several times daily

Other

How does your pet typically eat?

Fast, ravenous

In one sitting, but not scarfing

Nibbles/grazes throughout the day

What are your pet's stools like?

Dry, pelleted, small

Loose, soft, watery

Mucousy

Normal

Purpose of your dog?

Pet

Sport

Working dog (Forensics, Search and Rescue, Police)

Show

Guard

Service

Has your pet had any adverse reactions to any medications?

Yes

No

Is your pet currently coughing or sneezing?

Coughing

Sneezing

Does your pet have any vomiting or diarrhea?

Vomiting

Diarrhea

Has there been any recent change in your pet's willingness to play or exercise?

Yes

No

Has your pet lost or gained weight recently?

Loss

Gain

No change

Photo and Video Use *

We are asking for permission to utilize photos and/or videos of your pet and their story to be used for social media and promotional materials for Veterinary Acupuncture and Rehabilitation Services.

I give permission to utilize photos and/or videos of my pet.

I decline and would like to opt out.

Cancellation/Reschedule Policy *

By checking the boxes below, you acknowledge that you have fully read our policy and agree to adhere to it.

Please be advised that cancellations made up to 48 hours before a scheduled appointment via email, text or phone call will be processed without a penalty.

Cancellations made 48 hours or less before an appointment will be subject to a charge of half of the service rate. This includes appointments where our service provider is unable to access the property, is turned away, rescheduled appointments or the client is a no-show.

If Veterinary Acupuncture and Rehabilitation Services cancels an appointment with less than 48 hours notice, a new appointment will be scheduled without penalty to the client, subject to availability.

We require any communication regarding cancellation or rescheduling of appointments be done during business days and hours. Please note that we are closed on Saturdays, Sundays and holidays.

We have a non-refundable $150 booking fee policy in order to secure your initial appointment. We will require a credit card on file in order to reserve your animal’s initial appointment. If you choose to cancel, make changes or do not show up for your appointment the fee will be kept, otherwise it will be applied to your first appointment.

Credit Card Payment Authorization *

By checking the boxes below, you acknowledge that you have fully read our policy and agree to adhere to the following:

I understand that is is required to have my credit card saved on file to secure appointments with Veterinary Acupuncture Services and may be used for payment.

I understand that my credit card saved on file may be used in the event of a cancellation/rescheduling request is made in 48 hours or less (refer to our Cancellation/Reschedule policy above).

Consent for Canine Treatment *

By checking each box below, you acknowledge that you have fully read this consent information and understand its contents, implications and purpose.

I understand that results of acupuncture and physical rehabilitation cannot be guaranteed and that, as with any medical procedure, the risk of complications or injury is always present to some degree.

I understand that physical rehabilitation and/or acupuncture treatments can include various types of therapeutic exercise and physical modalities (such as cold therapy, heat therapy, low-level laser, electrical stimulation, etc.). It may also include some manual therapy. Complications of physical rehabilitation are uncommon, and include, but are not limited to: delayed healing, failure to improve, worsening of a condition. I consent to and authorize physical rehabilitation, if recommended by the veterinarian.

I understand that I will be given an at-home plan to continue my pet’s rehabilitation therapy in my home under my sole care. I agree to hold Dr. Allie Turner at Veterinary Acupuncture and Rehabilitation Services harmless from any and all liability, including any injury to myself resulting from the care that I provide to my pet. This includes, but is not limited to, bites from my pet, and any back, neck and/or muscle strain in myself or my pet.

I certify that I have not been given any medical promise of success or guarantee of outcome from services received. I understand that every medical condition is different and the outcomes are based on multiple factors.

In some cases, acupuncture may be offered as part of an animal’s treatment. Complications of acupuncture are uncommon, and include, but are not limited to: broken needle under the skin, needle ingestion, infection, bleeding, nerve damage, pneumothorax. I consent to and authorize the performance of acupuncture therapy, if recommended by the veterinarian.