Client Registration Form Title Name Address Post Code Telephone Home Work Mobile Email 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 Email 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. Send 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