Alternative Medicine Release Form

Client Name *

First

Last

Address

Address Line 1

City

State

Zip Code

Patient Name *

Breed *

Color *

DOB *

Species *

Canine
Feline
Equine

Sex *

Male
Neutered Male
Female
Spayed Female

I am aware that the following complementary and alternative modalities to be used in the treatment of my animal(s) are not considered conventional veterinary medicine:

Acupuncture
Chinese Herbal therapy
Traditional Chinese Food therapy
I have read and fully understand this Client Consent Form.
I am the owner of, or the authorized agent of, the animal described above and I am of legal age (18 years or older)
I consent to the provision of the above listed complementary and alternative modalities for my animal by the above-mentioned doctor.

Checkboxes *

I Understand

I am seeking complementary or alternative services (with/without) involvement of my veterinary practitioner. (please select option)

With
Without

By completing this form and returning it to Complete Animal Wellness and Longevity Medispa, I acknowledge that the state of Texas considers acupuncture, Chinese herbal therapy, Traditional Chinese Food therapy, Tui-Na body work and supplements to be alternative treatments and I agree to have my pet treated by her using these methods. *

I Agree

Signature *

Clear Signature

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Alternative/holistic Medicine Release Form

Alternative Medicine Release Form

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