Intake Forms

I, the undersigned, do hereby give my voluntary consent for the administration of acupuncture to my pet/animal. I understand that acupuncture is considered an alternate therapy in veterinary medicine. 

Acupuncture has been explained to me as a medical treatment performed by the insertion of sterile (single-use) acupuncture needles through the skin into the underlying tissues and muscles at specific points on the body for the purpose of alleviating pain and/or for treating other clinical conditions. 

Associated techniques of acupuncture may be used, including one or more of the following: acupressure, electroacupuncture, moxibustion, laser therapy, and aquapuncture. I understand that other relevant diagnostics and therapies may also be required to diagnose and treat my pet. I understand that a minimum of 3 to 5 treatments is often needed before a response to therapy may occur. I recognize that, as in all types of medicine, the response to therapy varies with each patient. I understand that positive effects may not be immediate and are often not noted for 3 days following a session. I realize that neither a guarantee nor warranty can ethically or professionally be made regarding the success of the treatment recommended. 

Acupuncture is considered to be extremely safe. Possible side effects of acupuncture, which can occur at any time during the course of therapy, have been explained to me and include the following: bleeding; possible temporary worsening of symptoms; bruising, redness, swelling, or soreness at the treated sites; transient weakness or lethargy post-treatment. 

I state that my pet/animal does not have any of the following: Pregnancy, Bleeding Disorder, Pacemaker. 

I state that my pet/animal has been evaluated by a veterinarian for the condition(s) being treated with acupuncture. *See optional statement below if you are the patient’s alternative/holistic care provider only. 

I understand that I assume all financial responsibility for the services rendered, and that full payment is due at the time services are rendered. I understand that hospital support personnel will be used as deemed necessary to perform and complete therapy. 

I certify that I have read and fully understand all the above terms regarding treatment of my pet/animal. I also certify that I have the authority to execute this consent. I also certify that by entering my name in the form below, it acts as my signature to this form.

*I understand that Stephanie Kotas, DVM is not the primary care veterinarian for my pet/animal and that she is operating with the understanding that I will continue to maintain a valid veterinarian-client-patient relationship with a primary care veterinarian for all of my pet’s needs other than the acupuncture/alternative care that she is providing. I understand that should my pet become ill, injured or painful, I should seek care from my primary care veterinarian or an emergency veterinary facility.