Owner of the animal described below, and being eighteen years of age or older, do understand, substantiate, and authorize the following:

1) Dr. Denver Doyle & Dr. Darby Doyle are Doctors of Chiropractic, licensed in the care of humans. Both have attended several hundred hours of education
specific to Animal Chiropractic, and have both been certified in Animal Chiropractic by the American Veterinary Chiropractic Association. Dr. Denver Doyle has
additional certification through the International Veterinary Chiropractic Association

2) Dr. Denver Doyle & Dr. Darby Doyle ARE NOT veterinarians, and cannot take responsibility for the primary care of my animal. Scope: Chiropractic is an
alternative, non-primary treatment. It does not replace traditional veterinary care, medication, or surgery.

3) Chiropractic Care IS NOT intended to replace traditional veterinary care, but is considered an Alternative Therapy, to be used concurrently and in conjunction
with my Veterinarian's care. Veterinary Oversight: Chiropractic care is provided concurrently with veterinary care, and must be under supervision or referral by a
licensed veterinarian, per Kansas Law.

4) I understand that there is minimal research supporting the clinical efficacy of Animal Chiropractic, and that some aspects of my animal's care may be used in
future research data, Efficacy & Risk: There is limited research on animal chiropractic outcomes. The scope, risks, and benefits of care have been explained. I
understand no outcome is guaranteed.

5) Dr. Denver Doyle & or Dr. Darby Doyle has explained to me the scope of their care, and described the procedures he will perform on my animal. I understand
them, and acknowledge that they agree with the American Veterinary Medical Association's (AVMA) description of Animal Chiropractic as follows: "Veterinary
chiropractic is the examination, diagnosis, and treatment of nonhuman animals through manipulation and adjustments of specific joints and cranial sutures...
[Veterinary chiropractic DOES NOT] include dispensing medication, performing surgery, injecting medications, recommending supplements, or replacing
traditional veterinary care.. The assurance of education in veterinary chiropractic is central to the ability of the veterinary profession to provide this service...
Some areas of the country do not have an adequate supply of veterinarians educated in veterinary chiropractic. Therefore, it is recommended that, were the
state's practice act permit, licensed chiropractors educated in veterinary chiropractic be allowed to practice this modality under the supervision of, OR REFERRAL
BY [my capitalization], a licensed veterinarian who is providing concurrent care.

6) Dr. Denver Doyle & Dr. Darby Doyle have explained the risks involved with Animal Chiropractic care to my satisfaction, and I realize that there can be no
guarantee as to the nature of my animal's condition or the outcome of any procedure.

Liability: I accept responsibility for any harm caused by my animal and hold Full Circle Animal Chiropractic and its practitioners harmless.

7) Record Sharing: I authorize sharing of records between Full Circle Animal Chiropractic and my animal's veterinary or care team.

8) Insurance & Fees: I understand Full Circle does not submit to insurance providers. Receipts will be given for owner-initiated claims. Full Circle Animal
Chiropractic has made me aware of their fee schedul. I agree to pay a the time of service of services renderede and for travel costs accrued. I do understand and
consent that FCAC 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 furture services if I have a balance on my account.

9) Payment & Policy: I understand payment is due at time of service and that cancellation fees may apply if notice is not given 24 hours in advance.

10) Ful Circle Animal Chiropractic has explained their scope of practice and the procedures to be performed. They have explained the risks and benefits of
treatment to my satisfaction. I understand that there is no gurantee to the nature of my animal's condition or the resulting outcomes of treatment. I understand
Full Circle Animal Chiropractic intent is to do no harm, but I also understand that negative reactions to treatment can occur. I will indrmnify and hold harmless Full
Circle Chiropractic and my referring veterinarian should any negative reactions occur.

I hereby authorize Full Circle Animal Chiropractic Services, and in particular, Dr. Denver Doyle & Dr. Darby Doyle, Chiropractic Physicians, to treat my animal with Veterinary Chiropractic. I certify that my animal has had regular, traditional veterinary care, and is now concurrently being treated by:

I also certify that I have been open and honest with Dr. Denver Doyle & Dr. Darby Doyle as to any and all other examinations, diagnostic tests, diagnoses, and
treatments for my animals conditions.

I have read this authorization form, and understand it and give my consent.