Companion Animal Chiropractic, LLC Consent for Animal Chiropractic Examination and Treatment
Please read and acknowledge the following information before authorizing chiropractic care for your animal. Complete all required fields to provide informed consent.
Acknowledgements
I understand that Companion Animal Chiropractic, LLC employs licensed chiropractors and/or veterinarians who have completed advanced post-graduate education in spinal manipulation, and that chiropractors employed are not veterinarians unless otherwise noted and cannot take responsibility for the primary care of my animal.
*
I acknowledge and agree.
I understand that my animal may be photographed or videoed for clinical and/or marketing use. I consent to the use of my pet’s first name and image on the Companion Animal Chiropractic LLC website or social media accounts. I understand my personal information will remain private, and I may request removal of my pet’s images at any time by submitting a written request.
*
I consent.
I do not give permission for my animal's photo to be used for marketing.
I certify that I have been open and honest regarding all examinations, diagnostic tests, diagnoses, treatments, and bite/aggression history related to my animal.
*
I certify.
I hereby authorize Companion Animal Chiropractic LLC and their licensed providers to treat my animal with veterinary spinal manipulative therapy and/or rehabilitation. I certify that my animal has had routine veterinary care and that my veterinarian has referred me to this service.
*
I authorize and certify.
Veterinarian (if a specific doctor)
Vet Clinic/Hospital
*
Animal Name(s)
*
Owner’s Name
*
Owner’s Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: