Consent Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Pet's Name *BreedAge (years) *Age (months)Sex *— Select Choice —Male EntireMale NeuteredFemale EntireFemale NeuteredI hereby give full permission for the animal described to undergo:CHRONIC PAIN ASSESSMENT AND TREATMENT AS DISCUSSED (tick all that apply)I understand that all veterinary treatment involves some risk and complications arising from the above procedures have been explained to me.I understand that Metta Pet Clinic may make recommendations to my primary care Veterinary surgeon regarding alterations in medications and diet to the above animal. I therefore allow data relating to my pet to be passed back to the primary care Veterinary surgeon.I understand that Metta Pet Clinic does not offer any additional medical services including blood tests, radiography and other diagnostics and that primary and emergency care of the animal named above will remain with the primary care Veterinary surgeon. However, Metta patients can be seen at MiNight Vet in Canterbury if they are unable to contact another practice if a pet’s welfare is in question/at risk and a client turns to them for help. Clients should be aware that staff at emergency clinics, like at their primary care facility, may not have training in holistic treatment so non urgent advice regarding their animal’s treatment should be directed to Sarah at Metta Pet Clinic.I understand that recommendations may include using medications which are unlicensed where there is no suitable authorised veterinary medicinal product available.In the event of a tertiary referral to a Specialist Centre or other paraprofessional I agree to allow data relating to my pet (i.e. pet and owner name, contact details, clinical history and investigative findings, treatment) to be passed to the relevant institution in order to facilitate the referral.I agree to the cost of treatment for the above animal:Cost £ AS – Terms and Conditions of Business I accept the terms and conditionsCommencement and Termination This agreement shall commence on the date above and will continue until terminated. This agreement can be terminated by either party giving written notice to the other party at the written address detailed above. Fees All fees are subject to VAT at the current rate. Fee levels are determined by the time spent on a case and the materials and consumables used. Chronic pain clinic telephone consultation, photo and questionnaire analysis – £100 Chronic pain in person appointment, pain score and gait assessment – £175 (additional fee’s apply if consultation is over 80mins or if medical histories take over the allocated 90 minutes to read) Initial acupuncture consult fee – £70, treatment -£55 (£125); subsequent acupuncture consultation fee – £50, treatment £40 (£90) per session Integrative Herbal medicine consultation – £175 Consultation fee thereafter (per 30 mins) – £60 Herbal medicine formulation fee for ongoing patients – £20 Herbal medicines price depends on herbs and weight of animal Laser treatment – £30 Visit fees varies depending on distance. Insurance form fee £10 Prescription fee – £18 These costs comprise consultation and treatment. Payment is required at each treatment. Card and cash payments are accepted, card/BACS is preferred. No direct insurance claims are available. iZettle link can be sent but will incur a 3% fee. Treatment Charges Metta Pet Clinic will happily provide a written estimate as to the probable costs of treatment if requested. Please bear in mind that the number of treatments will vary depending on the condition we are treating. Failure to pay invoice within 4 weeks will result in additional fees and/or debt collection. Ownership of Records Case records are the property of your veterinary practice and will be retained by them. Copies with a summary of the history will be passed on request to another veterinary surgeon taking over the case. In addition, a copy of the findings (identified by the pet and owner surname) will be retained by Metta Pet Clinic. Veterinary Consent For the benefit of continuity of care, Metta will request a copy of your pet’s medical history from their primary care veterinary surgery and an appointment request form will be sent to your vet so they are aware that we will be seeing your pet alongside the care they are already giving. Owners or handlers are required to notify Metta Pet Clinic if there have been any changes to medication or their condition since their last appointment. Liability Metta Pet Clinic can make no representations, warranties or guarantees as to the effectiveness of myotherapy, laser, herbal treatment, laser or acupuncture provided to the animal named above and the client acknowledges this. Cancellation policy If a session is cancelled or an appointment is broken with less than 48 hours’ notice, the full treatment fee will be charged unless there are extenuating circumstances which have been bought to Sarah’s attention. Metta Pet Clinic reserve the right to cancel any treatments due to unforeseen circumstances and will try to give as much notice as possible. Please contact Metta Pet Clinic if your pet has an infectious or contagious condition such as kennel cough or gastroenteritis as they should not attend their appointment. No charge will be made. General Data Protection Regulation Metta Pet Clinic keeps secure digital records of your name, pet’s name, address, email address, telephone numbers, relevant medical history and consultation notes utilising AcuroVet software, Trello and Google workspace.Where paper documents are required (for example consent forms) these are kept in lockable storage. Information is shared with your referring primary care veterinary practice and may be shared with a tertiary referral veterinary practice or paraprofessional as required. Stored information is updated regularly. Digital Signature or Owner – Name *FirstLastBy signing this form, I understand that I am accepting the terms and conditions of business which are set out above.Email *Submit Consent Form