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I hereby authorize Healing Arts Animal Care to perform acupuncture on my pet.*

Yes

I have read the sheet/web page entitled “Veterinary Acupuncture” and understand the procedures, benefits, risks and possible side effects.*

Yes

http://healingartsanimalcare.com/acupuncture-2/

This authorization serves for today and further treatments unless revoked in writing.*

Yes

I certify that I have not been made any medical promise of success or guarantee of outcome of service. I understand that every medical condition is different and outcomes are based upon multiple factors.*

Yes

I have fully read this consent information and understand its contents, implications and purpose.*

Yes

I give permission for photos/videos of my pet and their health story to be used for social media, speaking engagements, and promotional materials for Healing Arts Animal Care.*

Yes
No

I understand and agree that all payments are due when services are rendered.*

Yes

Signature*

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Acupuncture Release Form

Acupuncture Release Form