INFORMED CONSENT
I, *, have read the consent below and understand, authorize, give consent, and can substantiate the following. I intend this consent to cover the entire course of care from Atlas Animal + Family Chiropractic, LLC for the treatment of present condition(s) and for any future condition(s) for which I seek chiropractic care for my animal. I hereby authorize Atlas Animal + Family Chiropractic, LLC to examine and provide chiropractic care to my animal(s), if there are no contraindications. I am/ will be honest with all the information that I provide and will share any other services, diagnoses, or examinations that my animal receives, and I verify that my animal is under current veterinary care.
Before an animal is seen, our animal chiropractors will go over the intake form. A health history and physical examination will be done to assess the animal's health and determine if chiropractic care is appropriate for your animal.
I understand animal chiropractic does NOT replace traditional veterinary medicine. Employees of Atlas do not intend to replace traditional veterinary care or take responsibility for the primary healthcare need of the animal(s). I understand animal chiropractic is a complementary method to add to an animal's health care.
I understand that if I choose to use animal chiropractic services that I will also concurrently be working with my veterinarian to address any primary healthcare needs that my animal has. Dispensing/injecting medication, performing surgery, recommending supplements, or providing any traditional veterinary care is NOT included in chiropractic care.
I understand that if there is an emergency that I need to contact my veterinarian or an emergency veterinarian clinic/hospital, as Atlas Animal + Family Chiropractic is not an emergency service.
CREDENTIALS: I understand that employees of Atlas Animal + Family Chiropractic are Doctors of Chiropractic (licensed in human health care) and are NOT veterinarians. These Doctors of Chiropractic have completed 240+ hours of animal chiropractic education through a postgraduate animal chiropractic approved course. They are board certified through the American Veterinary Chiropractic Association (AVCA) and will continue to stay up to date with animal chiropractic continuing education. These courses and certifications provide information and skills in order to safely and effectively adjust animals.
SCOPE: Atlas Animal + Family Chiropractic, LLC has explained their scope of practice and the procedures to be performed. Benefits of adjustments may include improving joint motion, reducing inflammation/swelling in a joint, decrease pain, neurological function improvement, and mobility improvement. They have explained risks and benefits of treatment to my satisfaction. I understand that there is no guarantee to the nature of my animal's condition or the resulting outcomes of treatment. Many patients feel stiff, sore, or achy for a few days following their adjustment. This is common and expected. However, I understand that no service/procedure comes without risk. I understand Atlas Animal + Family Chiropractic's intent is to do no harm, but I also understand that negative reactions to treatment can occur (such as, but not limited to: fracture, dislocation, disc injury, strain/sprain, worsening of present condition, stroke, or neurologic impairment). I will indemnify and hold harmless Atlas Animal + Family Chiropractic, LLC and my referring veterinarian should any negative reactions occur.
RECORD SHARING: I hereby allow Atlas Animal + Family Chiropractic and my primary veterinarian to share any and all records so they may collaborate on my animal's care. I allow Atlas to share records with any and all members of my animal's care team. I also allow the use of my animal's health information for research purposes.
LIABILITY: I understand that results are not guaranteed. I agree to hold my provider harmless for claims or damages in connection with my animal's treatment. This is a contract between myself and my provider, and I understand that it is also a release of potential liability. Atlas Animal + Family Chiropractic, LLC has made me aware that they carry their own malpractice and liability insurance. However, I understand that I am solely responsible for any harm caused by my animal to myself or any other animal, person, or property while under Atlas Animal + Family Chiropractic's care. This includes any financial obligation that may result due to my animal's behavior.
FEES: Atlas Animal + Family Chiropractic, LLC has made me aware of their fee schedule. I agree to pay at the time of service for services rendered and for travel costs accrued. I do understand and consent that Atlas Animal + Family Chiropractic may save my payment information and can charge cancellation fees if I do not cancel within 24-hour notice of my appointment. I understand that they can deny any future services if I have a credit on my account.
PET INSURANCE: I understand that Atlas Animal + Family Chiropractic is not a contracted provider with any insurance companies. My insurance policy is a relationship between myself and my insurer. Upon each service, I will be provided a detailed receipt that I may use for my own submission to my insurer. In submission, I understand there is no guarantee for reimbursement for services rendered, and I do not hold Atlas Animal + Family Chiropractic responsible for providing any records or receipts to my insurance company, as they have provided them to me, the owner, directly.
DENIAL OF SERVICES: I understand that my provider is allowed to deny services/treatment should there be a concern for my animal's well being or need for further diagnostic evaluation of their condition. I do not expect the provider to be able to anticipate and explain all risks and complications without proper information. I understand it is my responsibility to tell my provider about any and all of my animal's medical history so they can make an informed decision when treating my animal. Shall I choose to not disclose my animal's full medical history, I assume full responsibility for what negative reactions may occur in reaction to treatment.
CANCELLATION POLICY: I understand that if I do not cancel an appointment within 24 hours of appointment time, Atlas Animal + Family Chiropractic will charge me a "cancellation" fee of half of the service (new patient examination, reactivation examination, or adjustment appointment). If I no show an appointment, and the chiropractor shows up to where my animal resides, I will be charged for the full service and travel time. If a late cancellation happens multiple times, my animal may be dismissed as a patient.
For any other questions or information, please refer to the polices that are on the website or can be sent to you by email.
By signing below, I understand that I am certifying that I have read the above consent and all the information that I have provided is complete, true, and correct to the best of my knowledge and is made in good faith.