Name *

First Name

Last Name

I certify that I am the owner or authorized agent for the owner of the animal. *

I certify

I request that Arielle Walton, D.V.M., C.V.A. ( Dr. Arielle) perform the services which are necessary for the examination, medical treatment, and therapy of the animal listed above. I understand that Dr. Arielle is using methods of treatment including, but not limited to acupuncture, nutritional supplements, home-cooked diets, and Traditional Chinese herbs, some of which may not be recognized as standard methods of treatment by the AVMA (American Veterinary Medical Association). The nature and purpose of the procedures and methods of treatment, the risk involved, and the possibility of complications have been fully explained to me. Possible side effects include, but are not limited to, local inflammation, bleeding, broken needles, and swallowed needles. If these occur, additional diagnostics and treatments may b required at the pet owner’s expense. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained, just as with conventional medical treatments. I understand that the treatment of the patient will be conducted with professionalism and in accordance with prevailing standards of competency in veterinary acupuncture and Traditional Chinese herbal medicine as recognized by the Chi Institute of Traditional Chinese Veterinary Medicine and the AAVA ( American Academy of Veterinary Acupuncture). I understand that I need to maintain a client/patient relationship with my referring veterinarian. Dr. Arielle is not available on an emergency basis and in case of an emergency, I will contact my referring hospital or local emergency animal hospital. I assume full financial responsibility for all charges incurred to the patient for services rendered and understand that payment is required at the time of service. I understand there are no refunds of services or prescribed herbal medications. I agree to pay all costs of litigation incurred in the collection of past due accounts. I understand that written estimates of charges are available upon request. This agreement shall remain in effect until such tie as a different agreement is executed. *

I authorize

I do not authorize

I authorize Dr. Arielle Walton to share photos, videos, testimonials, stories, or general information about my pet on her website or social media accounts. * *

I authorize

I do not authorize