I hereby authorize and consent to the performance of Acupuncture procedures in the treatment of my pet.

I understand that Acupuncture is considered an alternative medical therapy. I understand that Acupuncture will be used in conjunction with conventional medicaltherapy to provide the most comprehensive treatment plan for my pet.

The various Acupuncture techniques that may be utilized in treatment have been adequately described and discussed with me. I understand that these Acupuncture techniques are regarded as generally being safe without many sicle effects. However, some of the side effects that can occur include - but not limited to - bruising at the sight of needle insertion, mild bleeding at the sight of needle insertion, breaking of a needle,and mild tingling at the site of needle insertion. ln addition, it is not unusual that a patient may be more lethargic and quiet following an Acupuncture session.

I realize that neither a guarantee nor warranty can ethically or professionally be made regarding the success of the treatment recommended. I recognize that, as in all types of medicine, the response to therapy varies with each patient. I understand that positive effects may not be immediate and are often not noted for 3 days following a session. I also understand that if after 5 sessions no improvement is noted that Acupuncture maybe deemed an ineffective treatment option for the condition affecting my pet.

I understand that my pet's treatment may consist of needles only, needles with electrical stimulation, or needles with moxibustion (burning of a substance). I accept that for the confort and relaxation of my pet, other procesdures such as nail trims, blood draws, vaccinations, ear cleanings, and/or other irritating procedures should be sceduled as separate appointments.

After presentation of a medical care plan and written estimate of costs by my pet's attending doctorm I hereby consent to the provision of required diagnostic procesdures and acu[puncture by the attending doctor(s) and practice health care team at this facility. In the absence of negligence, I agree to hold these parties harmless for the absence of response to treatment or any ill effects experienced by my pet.

I understand that I assume all financial responsibility for the services rendered, and that full payment is due at the time services are rendered. I understand that hospital support personnel will be used as deemed necessary to perform and complete therapy.