I am aware that acupuncture can help many animals, but like any therapy, it will not help every pet. If the history and physical examination leads to the conclusion that acupuncture is not appropriate for my pet, I understand that Dr. Deanna will refer me to my pet’s primary care veterinarian for further care.

I understand that the acupuncture session may consist of needles only, needles with electrical stimulation, heat applied using a moxa roll, or the injection of liquid under the skin. I authorise Dr Deanna to perform Acupuncture and Acupuncture related medical procedure(s) and/or treatment(s) on my pet.

I acknowledge and understand that although acupuncture is regarded as generally safe without many side effects, unknown and unanticipated risks and complications could occur including but not limited to: mild bleeding or bruising at needle insertion site, breaking or ingestion of a needle, and mild tingling at needle insertion site. I realise that guaranteed results cannot ethically or professionally be made regarding the success of the treatment recommended and that the response to therapy varies with each patient. If any event were to occur, I am aware that I am not relieved of any obligation to all reasonable costs incurred regarding my pet.

PAYMENT DUE AT TIME OF SERVICE: I understand that I assume all financial responsibility for services rendered, and that full payment is due at the time of service. We accept Visa, Mastercard, Debit, Cash or Direct Deposit. We do not accept Payment Plans such as Vet pay or After pay. 

By checking the box, I am certifying that I am the owner of the patient named above, agree to the above statements, and that I have the authority to execute consent for this procedure.