As the owner of this animal, I hereby request authorization for veterinarian referral and consent for chiropractic examination and treatment of the animal listed below. I request for the chiropractic services to be provided by Dr. Heather Peters, D.C. with HBG Chiropractic, LLC. I understand that under Indaiana law, Dr. Heather Peters with HBG Chiropractic, will not examine or provide chiropractic treatment to my animal without obtaining consent from my primary veterinarian. I also understand that chiropractic care is an alternative therapy and shall not replace traditional veterinarian medicine provided by my primary veterinarian and that I should seek diagnosis of conditions from my veterinarian and follow their recommendations.