Acupuncture Consent Form

I hereby certify that I am the owner or an authorized agent of the owner for the above named pet and am over the age of 18. I understand that HeartFire Veterinary

Holistic Health Care is not a full service veterinary hospital and any routine medical and emergency care will be referred to your primary veterinarian. I am aware that acupuncture can help many animals deal with painful situations and recover from various medical maladies but I understand that this form of therapy may not help every patient. If the history and physical exam leads to the conclusion that acupuncture is not appropriate for my pet, I understand that Dr. Kayser may discuss other diagnostic and/or treatment options. Most conditions where acupuncture is likely to help require a minimum of 3-5 initial weekly sessions then sessions will become further apart depending on each case’s response. As a rule, the more chronic a problem, the longer the treatment may take. In many cases herbal formulations may also be recommended and herbs may take 1-3 weeks to show improvement. Again, as a rule, the use of herbs with acupuncture will yield a greater response. Though acupuncture is considered very safe if performed by a trained professional, some animals may not respond as expected. I understand if my pet is not responding as expected, Dr. Kayser may have to alter her initial diagnostic plan including changes in herbal medication or frequency of acupuncture treatments.

I have been informed that for lameness and arthritic conditions, it is recommended that my referring veterinarian should already have taken radiographs of the affected
area and supplied a copy of the report. This is essential to help rule out problems such as cancer or infection that are unlikely to respond to acupuncture therapy alone. Copies of previous blood work may also be requested to assist Dr. Kayser in treating your pet with acupuncture and herbs. If radiographs or blood work are deemed necessary by Dr. Kayser, I understand she may refer me back to my primary care veterinarian for such diagnostics.

I understand that my pet’s treatment may consist of needles only, needles with electrical stimulation, acupuncture using a class 3B laser or aqua-puncture (injection of Vitamin B 12 into acupuncture points). Please be aware that some animals, especially after their first and second treatment, may appear to be more
uncomfortable or exhibit sleepiness. Acupuncture cannot make a condition worse, it is however increasing blood flow and may exacerbate an issue temporarily. This should not last for longer than 24 hours. If it does please let Dr Kayser know. Typically patients are sleepy or more achy after treatment but will show improvements in the following days. These improvements will start to last longer and longer as we have more treatments. This is what allows us to start spreading treatment times further apart.

I accept that for the comfort and relaxation of my pet, I will leave other pets and small children at home and I will make every effort to remain calm and relaxed myself, as my emotions will affect my pet’s experience. If my pet becomes fractious, Dr. Kayser may attempt to use a muzzle and proceed with treatment but if this does
not calm my pet, Dr. Kayser may decide to end treatment for that session. Acupuncture will not work effectively if the patient is stressed.

I understand that practice of veterinary medicine and complementary veterinary medicine is not an exact science and thus, no guarantee for successful treatment has been made. I have been encouraged to discuss any questions I may have and have them answered to my satisfaction.

After presentation of a medical care plan and estimate of costs involved, I consent to acupuncture treatment by Dr. Kayser. In the absence of negligence, I agree to hold Dr. Kayser and HeartFire Veterinary Holistic Health Care harmless for absence of response to treatment or any ill effects experienced by my pet.
I agree to pay all costs incurred at the time of treatment unless previous arrangements have been made with Dr. Kayser.

Please sign the Client/Patient intake form to give HeartFire consent to do acupuncture.
Thank you!