I, owner of the animal described below and being 18 years of age or older, do understand, substantiate and authorize the following:
CREDENTIALS: Mar Chiropractic is comprised of Doctors of Chiropractic licensed in both the State of California and Arizona. Provider(s) of Mar Chiropractic have completed at least 226+ hours post-graduate training specific to spinal manipulation and is board certified by the American Veterinary Chiropractic Association to practice animal chiropractic.
Chiropractors employed by Mar Chiropractic are not veterinarians and cannot take responsibility for the primary care of my animal. Chiropractic care is not intended to replace traditional veterinary care, but is considered a ‘complimentary therapy’ to be used concurrently and in conjunction with my veterinarian’s care and recommendations.
The chiropractor, Mindy Mar, employed by Mar Chiropractic has explained to me the scope of care and described the procedures that will be performed on my animal. I understand those procedures and acknowledge that they agree with the American Veterinary Medical Association’s (AVMA) description of veterinary spinal manipulative therapy or animal chiropractic:
Veterinary chiropractic is the examination, diagnosis and treatment of non-human animals through spinal manipulation and adjustments of specific joints. The term ‘veterinary chiropractic’ should not be interpreted to include dispensing medication, performing surgery, injecting medications, recommending supplements or replacing traditional veterinary care. While sufficient research exists documenting efficacy of chiropractic in humans, research in veterinary chiropractic is limited. Sufficient clinical and anecdotal evidence exists to indicate veterinary chiropractic can be beneficial. It is recommended that further research be conducted in veterinary chiropractic to evaluate efficacy, indications, and limitations. The assurance of education in veterinary chiropractic is central to the ability of the veterinary profession to provide this service.
Licensed chiropractors who have earned sufficient certification through a state-approved program may perform animal chiropractic when animals are referred for care by their veterinarian.
2. SCOPE: The provider(s) of Mar Chiropractic are NOT veterinarians and they do not intend to replace traditional vet care or take responsibility for my animal’s primary healthcare needs.
I am seeking chiropractic for my animal(s) as a complementary therapy to be used concurrently with my current veterinary care. Chiropractic does NOT include: dispensing/injecting medication, performing surgery or providing any traditional veterinary care.
3. RECORD SHARING: I hereby allow Mar Chiropractic and my referring vet to share any and all records so they can better collaborate on my animal’s treatment. I’m aware I can request Mar Chiropractic to share my animal’s chiropractic records with any and all members of my animal care team upon request. I hereby also allow use of my pet’s health information for research purposes to advance the field of animal chiropractic.
4. INFORMED CONSENT: Mar Chiropractic has explained their scope of practice and the procedures to be performed. They have explained risks and benefits of treatment to my satisfaction. I understand that there is no guarantee to the nature of my animal’s condition or the resulting outcomes of treatment. I understand Mar Chiropractic intent is to do no harm, but I also understand that negative reactions to treatment can occur (such as, but not limited to: fracture, dislocation, disc injury, strain/sprain, worsening of present condition, stroke, or neurologic impairment.) I will indemnify and hold harmless Mar Chiropractic and my referring veterinarian should any negative reactions occur.
5. LIABILITY: Mar Chiropractic has made me aware that they carry their own malpractice and liability insurance. However, I understand that I am solely responsible for any harm caused by my animal to myself or any other animal, person, or property while under Mar Chiropractic care. This includes any financial obligation that may result due to my animal’s behavior.
8. FEES: Mar Chiropractic has made me aware of their fee schedule. I agree to pay at the time of service for services rendered and for travel costs accrued. I do understand and consent that Mar Chiropractic may save my payment information and can charge cancelation fees if I do not cancel within 12-24 hour notice of my appointment. I understand that they can deny future services if I have a credit on my account.
9. PET INSURANCE: I understand that Mar Chiropractic is not a contracted provider with any insurance companies. My insurance policy is a relationship between myself and my insurer. Upon request, I can be provided a detailed receipt that I may use for my own submission to my insurer. In submission, I understand there is no guarantee for reimbursement for services rendered and I do not hold Mar Chiropractic responsible for providing any records or receipts to my insurance company as they have provided them to me, the owner, directly.
I hereby authorize Mindy Mar D.C./Mar Chiropractic to treat my animal(s) with spinal manipulative therapy, animal chiropractic treatment(s) and/or rehabilitation. I certify that my animal has had routine, traditional veterinary care, and/or that my veterinarian has referred me to this service.
