1. I am the owner or agent of the pet described above. I have the authority to execute this consent as I am over the age of 18. I hereby consent to and authorize the administration of canine rehabilitation services based upon the initial intake and the referral form from the referring Veterinarian.
2. I understand and acknowledge that Dr. Jenelle Lauchman and Holistic Pet PT only provides animal rehabilitation. I understand that she is not a veterinarian and that I have a relationship with a regular veterinary clinic/hospital for routine and emergency veterinary services. If I have medical concerns regarding my canine I will reach out to my regular veterinary clinic and or (emergency) hospital.
3. I have had the eval and treatment fees outlined to me and agree to pay all such fees and charges at the time of service. I understand that appointments that are booked but are cancelled may be subject to a cancellation fee up to the full cost of the visit.
4. I understand that the procedures will be carried out by Dr. Jenelle Lauchman under her training as a animal physical therapist. I understand that the procedures carried out will be best suited for my pet and will be explained to me so that I can provide informed consent regarding all treatment options under her training. If Laser is elected to be used I will wear googles if I choose to remain in the room in which the procedure is being performed.
5. Dry needling (DN) is a skilled technique performed by a physical therapist using a single-use, single-insertion, sterile filiform needle, which is used to penetrate the skin or underlying tissue to effect change in body conditions, pain, movement, impairment and disability. Like any treatment there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving your consent for dry needling treatment.
Risks of the procedure: The most serious risk associated with DN is accidental puncture of a lung (pneumothorax). If this were to occur, it may require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe lung puncture, while rare, may require hospitalization.
Other risks may include bruising, infection or nerve injury. It should be noted that bruising is a common occurrence and should not be a concern. The monofilament needles are very small and do not have a cutting edge; the likelihood of any significant tissue trauma from DN is unlikely. Dry needling cannot be preformed on pregnant animals or over infected area.
6. I acknowledge that Holistic Pet PT aims to create a stress-free environment for my pet. However, I agree to notify Dr. Jenelle Lauchman of any behavioral issues my dog may have, including but not limited to sensitivity to touch, aggression, bite history and if my dog wears a muzzle or has required a muzzle in the past. I understand that Dr. Jenelle Lauchman may determine if treatment will be best carried out with a muzzle and have the right to decline treatment unless the canine is muzzled.
7. In order to be respectful of the needs of other clients, Holistic Pet PT requires at least 24 hours’ notice for appointment cancellations. Cancellations made with less than 24 hours’ notice, or missed appointments without notice, will be subject to a cancellation fee equal to the full visit fee.
8. I have been advised as to the nature and purpose of canine rehabilitation and realize that no guarantee exists as to the result of referring veterinary’s diagnosis, prognosis, and treatment of the pet above.
9. I understand that Dr. Jenelle Lauchman and Holistic Pet PT are a part of my pet’s comprehensive team of trained professionals and will be in contact with my regular, or referring veterinarian, as appropriate for my pet’s best interest and ongoing care.
Payment Policies
1. A 3% processing fee will be applied to all credit card transactions. No additional fee will be charged for payments made by cash, ACH, or bank transfer.
2. A 10% after-hours fee will be applied to appointments scheduled:
• Monday–Thursday: between 5:00 PM and 6:30 AM
• Friday: after 1:00 PM
• Saturday and Sunday: all day
Acknowledgment
By signing below, I acknowledge and agree to the above payment policies.
I have read and agree to the statements above in this consent