Consent Form
Dr. Sarah Frogget
Owner or responsible person's name
First Name
Last Name
Patient's name
Date
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Month
-
Day
Year
Date
I hereby request and consent to the performance of acupuncture treatments on the patient named below, for which I am responsible, by the below-named veterinarian. I understand I have the right to refuse any treatment suggested but must express this understandably to the veterinarian.
Yes
No
I understand that generally, acupuncture is a safe treatment and incidence of complication is very rare; however, there is a chance of unexpected complication that may include but is not limited to, bruising, tingling sensation at the needle sites, infection, spontaneous miscarriage, nerve damage, and organ puncture including lung puncture. I understand other side effects may occur. I agree to assume full financial responsibility for any arising complication or side effect. However, I also understand the above-mentioned veterinarian makes every effort to avoid complication and uses sterile needles for each treatment.
Yes
No
I do not expect the veterinarian to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on the veterinarian to exercise judgment during the course of treatment based on the facts then known and understand the actions taken are believed to be in the patient’s best interest. I understand results are not guaranteed.
Yes
No
I intend for this consent form to cover the entire course of treatment for the present condition and for any future conditions for which I seek treatment for the patient.
Yes
No
I agree to pay all charges incurred for services rendered at the time of treatment including acupuncture, house calls, returned check fees, etc. I agree to pay the full charge for any missed or forgotten appointments without 24-hour notice of cancellation.
Yes
No
Signature
Submit
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