Owner Name: *

First Name

Last Name

Phone: *

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Address for Home Visits: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Name: *

First Name

Last Name

Primary Veterinary Clinic: *

First Name

Last Name

Primary Veterinarian Name: *

First Name

Last Name

Primary Veterinarian Phone:

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

Yes

No

Video and Photo 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 Feline 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.