Veterinarian Authorization Form

Veterinarian Authorization Form

For Animal Chiropractic Services
1. CREDENTIALS: Full Circle Animal Chiropractic is composed of Doctors of Chiropractic licensed in human care. Employees / contractors of Full Circle Animal Chiropractic have completed postgraduate work in order to become certified by the American Veterinary Chiropractic Association / International Veterinary Chiropractic Association in order to safely and effectively practice on animals.
2. SCOPE: The employees / contractors of Full Circle Animal Chiropractic are not veterinarians and they do not intend to replace traditional vet care or take responsibility for said animal's primary healthcare needs. Animal owners are seeking chiropractic and/or rehabilitation for their animal(s) as a complementary means to be used concurrently with their current veterinary care. Kansas Law states: A limited statutory exception exists allowing a Chiropractor licensed under the KANSAS HEALING ARTS ACT to associate with a licensed Veterinarian whereby Chiropractic treatment of an animal may be delegated. K.S.A. 47-817(i) and K.A.R. 70-7-1(n). Any delegation MUST be either directly or indirectly supervised. Our care does NOT include: dispensing/injecting medication, performing surgery, recommending supplements, or providing any traditional veterinary care.
3. REFERRAL: Kansas law states: K.S.A. 47-816 (n) "Veterinary-client-patient relationship" means: (1) The veterinarian has assumed the responsibility for making medical judgments regarding the health of the animal or animals and the need for medical treatment, and the client, owner or other caretaker has agreed to follow the instruction of the veterinarian; (2) there is sufficient knowledge of the animal or animals by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition of the animal or animals. This means that the veterinarian has recently seen or is personally acquainted with the keeping and care of the animal or animals by virtue of an examination of the animal or animals, or by medically appropriate and timely visits to the premises where the animal or animals are kept, or both; and (3) the practicing veterinarian is readily available for follow up in case of adverse reactions or failure of the regimen of therapy. It is therefore recommended that in states where the practice act permits, a chiropractor working on animals must perform all services with REFERRAL from a licensed veterinarian providing concurrent care. See K.S.A. 47-816 Statutory language of the practice act & In rules regulations of the practice act K.A.R. 70-7-1
4. RECORD SHARING: I hereby allow Full Circle Animal Chiropractic to share any and all records so they can better collaborate on the animal's treatment. I allow Full Circle Animal Chiropractic to share records with any and all members of the animal care team (l.e: trainers, massage therapists, groomers, etc). Full Circle Animal Chiropractic will share any and all records with the veterinarian / veterinarian(s) / veterinarian office(s) associated with the animal's care after each and every visit. Calls will be made before any treatment is rendered and follow up calls will be made if necessary.
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5. INFORMED CONSENT: The patient's owner has signed/will sign our informed consent with Full Circle Animal Chiropractic statingthe following: "FCAC has explained their scope of practiceand the procedures to be performed. The owner understands that there is no guarantee to the nature of my animal's condition or
the resulting outcomes of treatment. The owner understands Full Circle Animal Chiropractic intent is to do no harm, but the owner also understands that negative reactions to treatment can occur. The Owner will indemnify and hold harmless Full Circle Animal Chiropractic and my referring veterinarian should any negative reactions occur."
6. LIABILITY: Full Circle Animal Chiropractic has made the owner aware that they carry their own malpractice and liability insurance.However, the owner understands that they're solely responsible for any harm caused by the animal to themselves or any other animal, person, or property while under Full Circle
Animal Chiropractic's care. This
includes any financial obligation that may result due to my animal's behavior.
7. PET INSURANCE: Full Circle Animal Chiropractic is not a contracted provider with any insurance companies. Any insurance policyis a relationship between the animal owner and their insurer. Upon each service, an owner will provided a detailed receipt that they
can use for their own submission to their insurer. In
submission, there is no guarantee for reimbursement for services rendered and an owner does not hold Full Circle Animal
Chiropractic responsible for providing
any records or receipts to their insurance company as they have provided them, the owner, directly.
8. POLICIES: Each owner has agreed to abide by the practice policies posted on Full Circle Animal Chiropractic's Website
9. VET REFERRAL AUTHORIZATION: Full Circle Animal Chiropractic will be have a signature on file for collaborative purposes inaccordance with the KSBHA, KCA, and DVM/DC Boards.
(FOR VETERINARIAN TO COMPLETE)
(PLEASE PRINT REFERRING/AUTHORIZING VETERINARIAN'S name ONLY)
in compliance with K.S.A. 47-816 have performed the following: 1. Established a valid veterinarian/client/patient relationship. 2. Examined the animal(s) to determine that the listed therapies are likely to be nonharmful. 3. Obtained a signed acknowledgement by the patient's owner (see above) that the listed therapies are considered under state law to be an alternative and nonstandard.
Animal(s) Name/Owner's Name (Required) :
Veterinarians Email (required) :
example@example.com
Veterinarians Phone Number (required) :
Format: (000) 000-0000.
Veterinarian Authorization Signature ONLY
Date

MonthDayYear
Date
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Should be Empty: