Client Registration Form

07341 207700
[email protected]
Cotestones Farm, Carnforth LA5 9NH

THE CATTERY
GALLERY
THERAPETICS
- Client Registration Form
- Vet Referral
THE CL
THE FARM
CONTACT US

THE CATTERY
GALLERY
THERAPETICS
- Client Registration Form
- Vet Referral
THE CL
THE FARM
CONTACT US

Title

Name

Address

Post Code

Telephone Home

Work

Mobile

Animal Details - Name

Age

Sex

Breed

Colour/Markings

Is your animal insured?

Yes No

Insurance Provider

Policy Number

Condition being claimed for which you are presenting for acupuncture?

Has this animal ever shown signs of aggression, nervousness or other behavoural problems?

Yes No

If yes please provide details.

Have you requested your vet to complete a vet referral form?

Yes No
PLEASE NOTE: It is essential that your vet completes a Referral Form on behalf of you/your pet prior to your first appointment. If this has not yet been done, please ask your vet to access and complete the form here cotestones.co.uk/referral

Veterinary Surgery Name

Telephone

Surgery Address

Clinical History Consent

I consent to you requesting the animal's clinical history.

Acceptance

I the owner/agent of the above animal, am giving my consent for a course of acupuncture therapy. I understand the techniques involved, the aims and the possible side effects. I am aware that my animal may some signs of discomfort during treatment. (If you require more information about the treatment methods, aims or side effects please contact us.)

I agree to inform my Theraptics Practitioner of any changes in the animal's medical condition during the acupuncture course including medications prescribed by the referring veterinary surgeon or the development of any infectious diseases.

I agree to pay at the end of each acupuncture session by cash or cheque. The current fee is £35 per session.

As acupuncture involves the use of sharps, I agree to take any necessary safety precautions, especially if children are present.

I understand that acupuncture is an act of veterinary surgery and should only be carried out by a trained veterinary acupuncturist. All Therapetics Practitoners have the appropriate training and insurances to carry out this treatment.

Name of Owner/Agent

Date

I agree to this site storing my submitted information in order to respond to this enquiry.

If you do not have a Vet Referral please ask your vet to complete the form at the button below or visit cotestones.co.uk/referral

Vet Referral Form

Cotestones Farm
Sand Lane
Warton
Carnforth LA5 9NH

07341 207700

[email protected]

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THE CATTERY
GALLERY
THERAPETICS
THE CL
THE FARM

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