INTEGRATIVE CARE CONSENT
Meridian Mobile Veterinary Care PLLC
Client’s Name: __________________________________ Patient’s Name: _______________________
I certify that I am the owner or authorized agent for the owner of the patient listed above. I also certify that I am over the age of eighteen.
I understand that acupuncture, laser, and Traditional Chinese Medicine are forms of complimentary or alternative medicine. Although they can be used to treat many conditions including (but not limited to) internal medical ailments and arthritis, they are best used in conjunction with conventional medical therapies. I authorize Meridian Mobile Veterinary Care PLLC to communicate with and coordinate care with my primary care veterinary clinic: __________________________________________________________________________________.
The Meridian Mobile Veterinary Care PLLC veterinarian will review my pet’s medical records and do thorough Western and Eastern physical examinations prior to treatment. If a condition is found that would contraindicate integrative therapy, I understand that no treatment will be performed, and that other recommendations for diagnostics or referrals will be made.
I acknowledge that Meridian Mobile Veterinary Care PLLC is capable of providing acupuncture, laser, and Traditional Chinese Medicine only. In the event that my pet needs additional diagnostics or care (including radiographs, blood work, surgery, and emergency care), I can return to my regular veterinarian or accept a referral to a specialty/emergency hospital or to Meridian Mobile Veterinary Care PLLC’s clinic partner.
I understand that acupuncture may involve needles alone, needles with electrical stimulation, moxibustion (the burning of an herb at acupuncture points), or aqua puncture (the injection of liquid vitamin B12 at acupuncture points).
Most conditions require multiple weekly treatments to determine if acupuncture or laser will be of benefit. After that, treatment can be continued at whatever frequency is needed to maintain results.*
*I understand that each animal responds differently to integrative care modalities and that no guarantee of successful treatment has been made. In the absence of negligence, I agree to hold Meridian Mobile Veterinary Care PLLC, its veterinarians, and its agents harmless for lack of response to treatment or any ill effects experienced by my pet resulting from said treatments. Further, I know of no condition that would adversely affect my pet as a result of integrative treatment.
I acknowledge that Meridian Mobile Veterinary Care PLLC does not allow photography or video recording during assessments or treatments.
I certify that my pet’s integrative care plan has been explained to my satisfaction and that any questions that I may have had prior to entering into treatment have been answered.
Signature: ________________________________________________________(seal) Date: ________