CONSENT FORM

Informed Consent for Class IV Therapeutic Laser and/or Acupuncture:

Laser therapy is a safe and effective therapy that is FDA cleared for the temporary relief of pain and reduction of symptoms associated with mild arthritis and muscle pain. Laser also promotes relaxation of muscle spasm and promotes vasodilation. Adverse effects from laser therapy are normally rare and temporary. Pain relief from laser therapy may be dramatic and substantial, lasting for hours, days or weeks. However, some results may be minimal or insignificant.  We generally recommend 4-6 treatments before considering a pet a "non-responder".

Adverse effects of laser therapy may occur from multiple causes including hypersensitivity, preexisting health conditions, thermal effects, excessive pressure from the probe, and laser over-stimulation.  Laser light can damage the retina in your eyes.  Always wear the laser protective glasses provided.  Contraindications to laser therapy include treatment of patients with a pacemaker, who are pregnant or have cancer.

I have been informed that acupuncture and electro-acupuncture are generally safe methods of treatment that utilize sterile needles and is done in a clean, safe environment by trained veterinarians.  But, as with all medical procedures, acupuncture treatment may have side effects including: bruising, numbness or tingling, minor bleeding, broken needles and ingested needles.  Increased sleep and tingling and soreness at the insertion site of the needle may last a few hours to a few days.  Very rare and unusual risks include dizziness, fainting, nerve damage, aggravation of existing symptoms, pneumothorax, organ puncture, infection and shock. Contraindications to acupuncture include pregnancy and pace makers. Additionally, electro-acupuncture should not be performed in patients with a history of seizures.  Care should be used in patients with cancer, diabetes and bleeding disorders.

I understand the risks of laser and acupuncture therapy and agree to the treatment program outlined for my pet by my veterinarian. I have read the above consent.  By signing below,  I agree to the above named procedures.  I intent this consent form to cover the entire course of treatment.  To the best of my knowledge, my pet does not have any of the aforementioned contraindications.

I acknowledge that I am using Highland Holistic Veterinary Care for holistic veterinary services which may include acupuncture, therapeutic laser, herbal supplements and food therapy.  I understand that Highland Holistic Veterinary Care is not my primary care veterinarian and will not provide any routine or emergency care services for my pet.  In the event that my pet has an emergency, I will contact my primary care veterinarian or emergency practice (Greenbrier Emergency Animal Hospital, 370 Greenbrier Drive, Charlottesville, VA 22901, 434-202-1616.)

Your Name:  _________________________________

Pet Name:  ___________________________________

Date: _______________________________________

Signature: ____________________________________