Consent to Treat | Balanced Pet Acupuncture

FORMS

Consent to Treat Form

If you are a new client, please complete and submit this form for your pet’s medical record before your appointment.

Authorization to Treat

Please complete and submit this form for your pet's medical record prior to your appointment.

Step 1 of 2

Last Name

First Name

Patient Name

Treatment Consent:

Acupuncture Information
Acupuncture is a form of Traditional Chinese Veterinary Medicine (TCVM) that involves the insertion of fine needles or fluids into specific points on the body to stimulate healing, reduce pain, and improve function. It can be used alone or in conjunction with conventional Western veterinary care.

Consent and Acknowledgement

I understand that acupuncture is a complementary therapy and may not replace traditional veterinary care.
I understand that while most animals tolerate acupuncture well, responses vary and may include mild soreness, lethargy, or temporary worsening of symptoms.
I understand that multiple sessions may be required for therapeutic effect, and no guarantee of cure or specific outcome is given.
I have informed the veterinarian of all known medical conditions and treatments my pet is currently receiving.
I consent to veterinary acupuncture treatment administered by a licensed veterinarian trained in acupuncture.
I understand that I may discontinue treatment at any time, and I agree to communicate any concerns with the treating veterinarian.
I understand that I am responsible for all treatment costs and fees incurred during each visit and that payment is due at the time of services.

(all boxes above must be checked to submit form)

Name with? have

By signing below, I acknowledge that I have read, understand, and consent to acupuncture treatment for my animal as described above.

Owner Signature

Clear Signature

Use touchscreen or mouse to sign your name

Authorization to Treat:

Please complete and submit this form for your pet's medical record prior to your appointment.

Step 1 of 2

Last Name

First Name

Patient Name

Treatment Consent:

Yes

I understand that acupuncture is a complementary therapy and may not replace traditional veterinary care.

Yes

I understand that while most animals tolerate acupuncture well, responses vary and may include mild soreness, lethargy, or temporary worsening of symptoms.

Yes

I understand that multiple sessions may be required for therapeutic effect, and no guarantee of cure or specific outcome is given.

Yes

I have informed the veterinarian of all known medical conditions and treatments my pet is currently receiving.

Yes

I consent to veterinary acupuncture treatment administered by a licensed veterinarian trained in acupuncture.

Yes

I understand that I may discontinue treatment at any time, and I agree to communicate any concerns with the treating veterinarian.

Yes

I understand that I am responsible for all treatment costs and fees incurred during each visit and that payment is due at the time of services.

By signing below, I acknowledge that I have read, understand, and consent to acupuncture treatment for my animal as described above.

Owner Signature

Clear Signature

Use touchscreen or mouse to sign your name

FORMS

Consent to Treat Form

Authorization to Treat

Treatment Consent:

Social Media Release

Authorization to Treat:

Treatment Consent:

Social Media Release

Contact Info