Clone of Animal PEMF Liability Release and Waiver Form

I hereby state that I am at least 18 years of age and have read, understand and agree to this Waiver and Liability Release Statement, that it is an informed release and that I intend to be legally bound by it.

Acupuncture: Acupuncture is one of the safest forms of medical treatment for animals when administered by a trained veterinarian. Side effects of acupuncture are rare and include bleeding, bruising, pneumothorax and soreness at the acupuncture site. An animal's condition may seem worse for up to 48 hours after treatment. Other animals become lethargic or sleepy for 24 hours. These effects are an indication that physiological changes are developing, and they are most often followed by an improvement in the animal's condition.

I, as the owner of the animal described above, consent to having Veterinary medical acupuncture on my animal.

I understand that there can be no guarantee as to the animal’s condition or reaction to or the outcome of any procedure/treatment undertaken. I declare that I voluntarily provide my informed consent.

Full Name*

First NameLast Name

E-mail

Phone Number*

Area CodePhone Number

State / Zip*

Street Address

Street Address Line 2

CityState

Zip Code

Type Animal*

DogCatExotic

Name of Animal 1

Name of Animal 2

Name of Animal 3

Name of Animal 4

By my signature below, I acknowledge that I have read the following, understand it and agree to the terms:

No one has made any representations or claims to me of any treatment or cure of any disease or condition; or any promise of any specific or general results of any kind regarding treatments on myself or on the animal I own or am in control of. I release from all general, medical and any other liability or claims of any kind; and, I indemnify and hold harmless, Finger Lakes Mobile Veterinary Services PLLC and associates and its respective officers, directors, agents, servants, employees, divisions, subsidiaries, shareholders, partners, members, affiliated companies related to the use of acupuncture. Should anyone acting on Signatory's behalf be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold harmless the Company, for all such fees and costs. I agree that this liability shall be interpreted and governed by the laws that the attending Practitioner resides in at the time of treatment.

Client's Signature*

Acupuncture treatment