Consent Form

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Consent Form

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Authorization

I hereby authorize and consent to the performance of holistic medicine (herbal medicine, acupuncture, chiropractic, homeopathy, and applied kinesiology) procedures in the treatment of my animal by INTEGRATIVE VETERINARY WELLNESS. I understand that holistic medicine is considered an alternative medical therapy by the AVMA. I understand that holistic medicine will be used in conjunction with conventional medical therapy to provide the most comprehensive treatment plan for my animal. The various holistic medicine techniques that may be utilized in treatment have been adequately described and discussed with me. *

I have read and agree

I understand that these holistic medicine techniques are regarded as generally being safe without many side effects. However, some of the side effects that can occur include – but not limited to – bruising at the sight of needle insertion, mild bleeding at the sight of needle insertion, breaking of a needle, and mild tingling at the site of needle insertion. In addition, it is not unusual that a patient may be more lethargic and quiet following a session. I realize that neither a guarantee nor warranty can ethically or professionally be made regarding the success of the treatment recommended. *

I have read and agree

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 that 3-5 treatments may be needed before adequate response to therapy is expected. By signing below, I acknowledge and understand the above statements and certify that my animal does not have any of the following conditions: pregnancy, a pacemaker, local skin infection, or any type of bleeding or clotting disorder (such as, vonWillerbran’s disease, hemophilia, immune mediated thrombocytopenia.) *

I have read and agree

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 Dr. Jennifer M. Smallwood is a licensed veterinarian holding an active license in Texas and she is a Certified Veterinary Acupuncturist (CVA), a Certified Canine Rehab Practitioner (CCRP), and is certified by the International Veterinary Chiropractic Association. *

I have read and agree

No show, cancellation and late patient policy: If you need to cancel an appointment we ask that you do so at least 24hrs in advance of your scheduled appointment time. If there are three or more scheduled appointments which you do not keep without prior cancellation or if there are repeated scheduled appointments in which you arrive fifteen minutes late, you could be subject to charges or dismissal from our practice *

I have read and agree

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In 2022, we gave 7% of our operating profit to non-profit organizations.

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