1. Acknowledgment of Understanding
I confirm that I am the owner of the patient presented for treatment and that I am over 18 years old. I understand that medical acupuncture is an alternative therapy that requires informed consent from the client, as mandated by Texas law.
2. Treatment Description
I consent to the administration of acupuncture by The Soothing Vet, which may include:
- Needle acupuncture
- Electroacupuncture
- Laser therapy
- Moxibustion
- Aquapuncture
These treatments are not limited to acupuncture and may include supplements, conventional diagnostic tests, or medications as deemed necessary.
3. Risks & Benefits
I acknowledge that the benefits of acupuncture may include pain relief, improved mobility, and overall wellness. I also understand that there are potential risks involved, which include but are not limited to:
- Mild bleeding or bruising at needle sites
- Temporary soreness, lethargy, or weakness
- A rare risk of needle breakage or infection
I acknowledge that no guarantee of outcome can or should be made. Additionally, I understand that some patients may not respond to acupuncture or supplementation and might require various other integrative therapies for relief, management, or treatment.
4. Alternatives & Risks of No Treatment
The Soothing Vet has explained the conventional treatment options available to me, as well as the potential risks of declining acupuncture, such as symptom progression and unresolved pain. I choose to proceed with acupuncture based on this informed discussion.
5. Contraindications
I affirm that my pet does not have any contraindicated conditions unless noted below:
- Pregnancy or being in heat
- Known bleeding disorders (e.g., hemophilia, platelet dysfunction)
- Implanted medical devices (e.g., pacemaker)
- Local infections at proposed treatment sites
6. Treatment Plan & Expected Sessions
I understand that 3 to 6 sessions are typically required to observe a therapeutic response. I consent to the recommended treatment plan and agree to follow the scheduling as advised.
7. Financial Responsibility
Full payment is required at the time of service, and we do not offer payment plans. We accept credit/debit cards, Zelle, and cash (cash payments receive a 10% discount). If your pet is covered by insurance, please contact your insurance provider directly to verify coverage eligibility and determine your reimbursement options. Payment will be collected from the responsible party (you) at the time of service. By signing below, you acknowledge that you understand and accept the payment policy and agree that no services will be provided without upfront payment.
8. Liability Release & Consent
I release and discharge The Soothing Vet and its agents from any liability related to the acupuncture treatment, except in cases of negligence by the practitioner. By signing below, I certify that I fully understand the content of this form and give permission to initiate acupuncture therapy for my pet.