Meridian Mobile Veterinary Care PLLC

Client’s Name: _______________________________________

Patient’s Name: ______________________________________

I certify that I am the owner or authorized agent for the owner of the patient listed above. I also certify that I am over the age of eighteen.

I understand that acupuncture is a form of complimentary or alternative medicine. Although acupuncture can be used to treat many conditions including (but not limited to) internal medical ailments and arthritis, it is best used in conjunction with conventional medical therapies. I authorize Meridian Mobile Veterinary Care PLLC to communicate with and coordinate care with my primary care veterinary clinic:


The Meridian Mobile Veterinary Care PLLC veterinarian will review my pet’s medical records and do thorough Western and Eastern physical examinations prior to treatment. If a condition is found that would contraindicate acupuncture (such as cancer or infection), I understand that acupuncture will not be performed, and that other recommendations for diagnostics or referrals will be made.

I acknowledge that Meridian Mobile Veterinary Care PLLCis capable of providing acupuncture, hospice care, and end-of-life services only. In the event that my pet needs additional diagnostics or care (including radiographs, blood work, surgery, and emergency care), I can return to my regular veterinarian or accept a referral to a specialty/emergency hospital or to Meridian Mobile Veterinary Care PLLC’s clinic partner.   

I understand that acupuncture may involve needles alone, needles with electrical stimulation, moxibustion (the burning of an herb at acupuncture points), or aqua puncture (the injection of liquid vitamin B12 at acupuncture points).

Most conditions require 4-6 weekly treatments to determine if acupuncture will be of benefit. After that, treatment can be continued at whatever frequency is needed to maintain results.*

*I understand that each animal responds differently to acupuncture and that no guarantee of successful treatment has been made. In the absence of negligence, I agree to hold Meridian Mobile Veterinary Care PLLC, its veterinarians, and its agents harmless for lack of response to treatment or any ill effects experienced by my pet resulting from said treatments.

I acknowledge that Meridian Mobile Veterinary Care PLLC does not allow photography or video recording during assessments or acupuncture treatments.

I certify that the acupuncture procedure has been explained to my satisfaction and that any questions that I may have had prior to entering into treatment have been answered.

Signature: ________________________________________________________________________   Date: ______________