Acupuncture Form (Part 3)

Red Maple Animal Hospital Acupuncture Intake Form

Pet owners can complete this electronic intake form for acupuncture services and provide health history, diagnostics, medication details, and authorization.
Record of Health Issues
Medical Condition 1
Medical Condition 2
Medical Condition 3
Medical Condition 4
Medical Condition 5
Diagnostic Tests
Diagnostic Test Entries
Current Medications, Supplements, and Herbs
Medication / Supplement / Herb Entries
Authorization
AUTHORIZATION TO PERFORM ALTERNATIVE THERAPY
I understand that the following are considered alternative forms of therapy and investigative by mainstream medicine:
● ACUPUNCTURE: including acupuncture, aquapuncture, electroacupuncture, laser therapy

I authorize Dr. Myers to perform alternative therapy on my pet and if any unforeseen condition arises calling in her judgment for procedures in addition to or different from those now contemplated, I further request and authorize her to do whatever she deems advisable.

The nature and purpose of the procedures, possible alternative methods of treatment risks involved and possibility of complications have been fully explained to me. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained.
Printed Name
Signature
Date

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Date
Should be Empty:

Red Maple Animal Hospital Acupuncture Intake Form