TCVM Questionnaire and Acupuncture Release

I state that the following conditions do not exist in my pet's current state of health: pregnancy or pacemaker.

I will immediately notify the practitioner of any changes regarding the following: pregnancy, pacemaker, organic condition, local infection, elevated risk of infection, seizure disorder, and/or bleeding disorder.

While acupuncture is generally considered safe, there can be complications that can arise because of treatment. I understand that there is the possibility of temporary complications that may result from acupuncture treatment, which include, but are not limited to, minor bleeding or bruising, minor pain or soreness, nausea, weakness, fatigue, or aggravation of existing symptoms for a short time. I understand that if any particular risks apply to my pet's case, my practitioner will discuss these with me. Additional complications that are considered rare, and include, but are not limited to: ingestion of needles, broken needles causing foreign bodies, infection at the needle insertion site, damage to nervous structures, and inadvertent puncture into joints and body cavities.

I acknowledge that herbal medications are not approved or regulated by the Federal Drug Administration.

I acknowledge that all medical practice carries both known and unknown risks and that no guarantee or assurance has been given to me regarding my animal's response to therapy.

I do not hold Canine Rehabilitation and Conditioning Group, LLC, or any of its representatives responsible for damage to animals that occur during or after treatment.

I certify that I have read and fully understand all the above terms regarding the treatment of my pet.

I also certify that I am over 18 and have the authority to execute this consent.

I authorize Canine Rehabilitation and Conditioning Group LLC to perform alternative therapy on my pet.

TCVM Questionnaire and Acupuncture Release

Authorization to Perform Alternative Therapy and Release of Liability