Consent Form NY Veterinary Acupuncture

Welcome and thank you for trusting us to care for your beloved pet. The purpose of this form is to explain the services we provide and allows us to treat your pet.

A TCVM exam will be needed in order to begin treatment as well as before any changes arise in order to provide the best help to your pet.

Acupuncture and integrative modalities: Acupuncture, (use of thin sterilized needles), Stimulation of those needles by electric stimulation (e-stim), application of heat in the form of moxibustion, massage, acupressure, herbal therapies, essential oils, vitamins, minerals, enzymes, therapeutic movement, injectable medications, Pulsed Electromagnetic Field Therapy (PEMF), laser therapy and dietary counseling. Most conditions will take 6-9 acupuncture and/or laser therapy treatments to see optimal improvement.

Herbal Medication: We may recommend herbal preparations and although considered "natural", these can result in adverse effects; including but not limited to: vomiting, diarrhea, and anorexia. Dr. Kristen Miller only buys chinese herbal medicine from a company that tests the purity of their products and are free of heavy metals.

It is important that the herbal medication prescribed be given as directed by Dr. Kristen Miller. If your pet experiences any problems in association with these substances, please stop administering them and contact Dr. Kristen Miller as soon as possible.

Acupuncture and holistic medicine are not intended to replace traditional veterinary care, but are considered integrative and complementary therapies, to be used concurrently and in conjunction with traditional veterinary care and recommendations of your animal’s primary veterinarian.

Dr. Kristen Miller does not provide general veterinary medical care and does not provide emergency services.

You may ask questions or raise concerns at any time during treatment and we will make reasonable efforts to give you all information possible in order to make informed decisions regarding the duration and appropriateness of continued care. You may stop treatment at any time.

You understand that an integrated approach may not be as rapid as pharmaceutical or surgical therapy, in that it may require more effort from the caretaker as compared to the simple administration of medication. Each animal is inherently unique and will respond to treatment in unique ways. Dr. Kristen Miller makes no promises or guarantees of cure or result of treatment.

Signature*

Name*

First NameLast Name

CONSENT TO TREATMENT and ASSUMPTION of LIABILITY
By signing this consent form, I (“I”) do hereby voluntarily give permission and consent for my pet(s) to be treated by Dr. Kristen Miller.

I acknowledge that I have been informed of the risks of treatment and have had the opportunities to ask questions pertaining to my animal. I understand that results are not guaranteed. I do not expect Dr. Kristen Miller to anticipate and explain every possible risk and its complications. I hereby waive, release, waive discharge, covenant not to sue indemnify and hold harmless, Dr. Kristen Miller, and any of its agents from any and all claims, demands, damages, costs, attorney fees, and liabilities relating to or arising directly or indirectly from services provided by Dr. Kristen Miller as well as any injuries or death suffered before, during or after care or consultation with Dr. Kristen Miller. I will not hold Dr. Kristen Miller and/or New York Veterinary Acupuncture P.C. responsible in the event that my animal bites or injures me during an appointnment.

I further expressly agree that the foregoing release is intended to be as broad and inclusive as permitted by the laws of the State of New York. I acknowledge that I am aware that I may hereafter discover facts in addition to or different from those which I know or believe to exist with respect to the subject matter of this Consent to Treatment and Assumption of Liability, but that it is my intention to hereby fully, finally and forever release all of the claims, disputes and differences known or unknown, suspected or unsuspected, which now exist or may exist. If any provision of this Release is found to be unenforceable or invalid, the remaining provisions shall be unaffected, binding and enforceable. If any action is brought to enforce or interpret the terms of this Agreement, the prevailing party shall be entitled to recover reasonable attorney’s fees, costs, and disbursements, in addition to any other relief that may be granted.

My signature below, verifies that I am the rightful owner, that I am over the age of 18 years and I consent to treatment. I acknowledge that I have been advised and my questions have been answered regarding the content of this document. I understand the potential risks incidental to the services provided and I fully assume all such risks. I intend this consent form to cover the entire course of treatment for my pets’ present condition as well as any future conditions for which I seek treatment from Dr. Kristen Miller. I understand that payment is due in full at the time of treatment.

Signature*

Name*

First NameLast Name

Consent to Use of Media Form

I give permission to Dr. Kristen Miller, NY Veterinary Acupuncture and Integrative Medicine, and her employees/staff/assistants to take photographs, motion pictures, video, or other audio/visual media of my pet which may be used for: patient medical records, educational purposes, Facebook, Instagram, website, newsletters, promotional material, and I also understand that there is no royalty, fee, or other compensation for such use. I agree to make no claim to them now or in the future, and release Dr. Kristen Miller and its employees and consultants from any liability in connection with the approved use of these materials.*

Yes, I agree to the Consent to Use of Media FormNo, I do not agree to the Consent to Use of Media Form

Signature*

Name*

First NameLast Name