Acupuncture Treatment and Care Plan

Please carefully read, understand and fill out the following.

* Indicates required field

Owners Name *

First

Last

Phone Number *

Email *

Pets Name *

General information and treatment costs for Acupuncture and TCM

This is a consent form for Resurge Veterinary Surgical Specialists and Rehabilitation LLC to preform acupuncture and traditional Chinese Medicine on your pets named above.

By signing this form below you are consenting to treatment and understand limitations of treatment, costs and details of the procedure.

Any balance for treatment(s) must be paid in full at the time of discharge.

Initial Acupuncture Consultation Cost is $150 (This includes acupuncture treatment the day of the consult.)
Ongoing Acupuncture Treatments will cost $90 per visit.

I hereby request and consent acupuncture treatments for my pet (who is listed above) and other procedures recommended by the staff of Resurge Veterinary Surgical Specialists and Rehabilitation. Acupuncture will only be preformed by a licensed DVM with advanced certification(CVA) in acupuncture and traditional Chinese Medicine. I understand that acupuncture is considered an alternate therapy in veterinary medicine. Methods of treatment may include, but are not limited to, acupuncture, electrical stimulation, aqua-acupuncture, moxibustion, Tui Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that Chinese Herbs may need to be prepared to the instructions provided orally and in writing.

Acupuncture is a medical treatment performed by insertion of sterile (single-use) acupuncture needles through the skin into the underlying tissues and muscles at specific points on the body for the purpose of alleviating pain and/or for treating other clinical conditions. I understand that most conditions where acupuncture is likely to help require a minimum of 3-5 initial sessions and thereafter, treatments may need to be continued over time. I understand 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 are often not noted for 3 days following a session. I also understand that if after 5 sessions no improvement was seen, acupuncture may be deemed an ineffective treatment option for the condition affecting my pet.

Acupuncture is considered to be generally safe. 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. Burns and/or scarring are a potential risk of Moxibustion. Unusual side effects of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. In addition, it is not unusual that a patient may be tired and quieter following an Acupuncture session. I understand that it is my responsibility to notify any member of the clinical staff of any adverse side effects that my pet may experience after receiving acupuncture treatments.

By signing at the bottom of this page you state that you understand the major risks of treatment, and other side effects may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, though some may be toxic in higher doses. The herbs may have an unpleasant smell or taste to my pet. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, itching, and hives. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I understand that some herbs may be inappropriate during pregnancy. I will notify a clinical staff member if my pet becomes pregnant.

Please sign your name here if you understand and except the above statements on general information and treatment costs *

Contraindications

Please check all that apply *

To my knowledge, my pet does NOT have any history of seizure activity or a bleeding disorder (e.g. von Willebrand's disease, hemophilia, immune-mediated thrombocytopenia). To my knowledge, my pet does NOT have any metal implants, a pacemaker or a local infection (skin infection, abscess, etc).

If your pet has 1 or more of the above problems or conditions please comment below. *

Please select 1 of the options below *

I do NOT consent to acupuncture treatment for my pet I do consent to acupuncture treatment for my pet as described above

CPR and advanced life saving

In the event of cardiopulmonary arrest or other emergent life-threatening situations Resurge Veterinary Surgical Specialists & Rehabilitation, LLC can perform life-saving measures on your pet. This may include the administration of medications, chest compressions, oxygen, ventilation, and other emergency measures deemed medically appropriate. I understand that the cost of life saving measures will be my responsibility. *

Sign your name below *

Submit

Acupuncture Consent form

Please carefully read, understand and fill out the following.

General information and treatment costs for Acupuncture and TCM

Contraindications

CPR and advanced life saving

Home
Services
About
Contact
Blog
Client Registration Form
Veterinary Referral information

Contact Us
phone: 985-888-1059
email: [email protected]

Location
641 River Highlands Blvd. Covington, LA 70433.

Acupuncture Consent form

Please carefully read, understand and fill out the following.

General information and treatment costs for Acupuncture and TCM

Contraindications

CPR and advanced life saving

HomeServicesAboutContactBlogClient Registration Form​Veterinary Referral information

Contact Usphone: 985-888-1059email: [email protected]

Location641 River Highlands Blvd. Covington, LA 70433.

Home
Services
About
Contact
Blog
Client Registration Form
Veterinary Referral information

Contact Us
phone: 985-888-1059
email: [email protected]

Location
641 River Highlands Blvd. Covington, LA 70433.