New Client Form

Please complete the form below if you would like to schedule an appointment for acupuncture.

Records must be sent from your horse’s primary veterinarian to HighTideVet@gmail.com before an appointment can be made.

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Owner's Name (First and Last)

Owner's E-mail Address

Owner's Phone Number

Owner's Billing Address

City

State

Zip

Trainer or Agent Name (First and Last)

Trainer or Agent Phone Number

Trainer or Agent E-mail Address

Primary Veterinarian Name - Clients must have a valid Veterinarian-Client-Patient Relationship with a primary care veterinarian. An exam must have been performed by the primary care veterinarian within the last twelve months. High Tide Veterinary Services does not offer primary care or emergency services

Primary Veterinarian Practice Name

Primary Veterinarian E-mail Address

Primary Veterinarian Phone Number

Patient Name

Patient Age

Patient Gender

Patient Species and Breed

Patient Activity or Competition Level

Patient Location if Different Than Billing Address - Include Gate Code

City

State

Zip

Select Payment Option

By checking this box you agree to pay for services provided in full at the time of service. If using card you authorise High Tide Veterinary Services to charge the credit/debit card provided for services rendered at the time of service.

By checking this box I consent to and authorize the performance of acupuncture therapy for my pet if recommended by the veterinarian. I acknowledge that acupuncture is considered to be a type of Complementary and Alternative Veterinary Medicine (CAVM). It is offered as a plan of integrative medicine, meaning it is used in combination with conventional veterinary medicine. It is NOT intended to replace conventional therapies, but instead may be recommended as an adjunctive therapy. Complications of acupuncture are rare. They may include, but are not limited to: Broken needle under the skin, needle ingestion, infection, bleeding, nerve damage, and pneumothorax.

By checking this box I agree I have been advised as to the nature of the therapy and the complications involved. I agree results cannot be guaranteed and complications are inherent to some degree in any medical procedure or treatment. I understand not all complications can be predicted, and that complications may result in prolonged hospitalisation and require additional diagnostic tests, treatments, procedures, and/or operations. I understand that the costs associated with any complication, including additional diagnostics, treatments, procedures, and/or surgery that may arise from the treatments or procedures performed are not the responsibility of High Tide Veterinary Services.

Should I request, or it become necessary, to handle my own animal, I waive the option of legal action against High Tide Veterinary Services in the event I am injured. In the event damages occur to my property while High Tide Veterinary Services is in attendance, I waive legal and financial action against High Tide Veterinary Services.

I am the owner or agent for the owner of the above described animal. I am mentally competent, under no duress or the influence of drugs or alcohol, and I am over the age of eighteen.

I understand that High Tide Veterinary Services does not provide primary veterinary care or emergency services. I agree that I have a current Veterinarian-Client-Patient Relationship with a primary veterinarian, which means that my pet has been seen by the primary veterinarian within the past twelve months.

I have read and understand this consent and voluntarily execute my authorization.

Full Name

Date