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Maddox Veterinary Chiropractic; Dr. Andrea Maddox, DVM

Licensed Veterinarian, Certified in Animal Chiropractic by the International Veterinary Chiropractic Association

www.maddoxchirovet.com

maddoxchirovet@gmail.com

Phone: (931-273-9599)

CHIROPRACTIC EXAMINATION & TREATMENT CONSENT FORM, AND CLIENT VERIFICATION OF CONCURRENT TRADITIONAL VETERINARY CARE

I, ______________________________________owner of the animal described below, and being eighteen years of age or older, do understand, substantiate, and authorize the following:

       1) Dr. Andrea Maddox is a Doctor of Veterinary Medicine. She has attended several hundred hours of education specific to Animal Chiropractic, and has been certified in Animal Chiropractic, by the International Veterinary Chiropractic Association.

       3) Chiropractic Care IS NOT intended to replace traditional veterinary care, but is considered Complimentary Therapy, to be used concurrently and in conjunction with my regular veterinarian's care.

       4) I understand that there is minimal research supporting the clinical efficacy of Animal Chiropractic, and that some aspects of my animal's care may be used in future research data.

       5) Dr. Maddox has explained to me the scope of her care, and described the procedures she will perform on my animal.  I understand those procedures and acknowledge that they agree with the American Veterinary Medical Association's (AVMA) description of Animal Chiropractic as follows:  "Veterinary [Animal] chiropractic is the examination, diagnosis, and treatment of nonhuman animals through manipulation and adjustments of specific joints and cranial sutures....  [Animal Chiropractic DOES NOT ] include dispensing medication, performing surgery, injecting medications, recommending supplements, or replacing traditional veterinary care....  The assurance of education in veterinary chiropractic is central to the ability of the veterinary profession to provide this service. 

       6) Dr. Andrea Maddox has explained the risks involved with Animal Chiropractic care to my satisfaction, and I realize that there can be no guarantee as to the nature of my animal's condition or the outcome of any procedure.

I hereby authorize Dr. Andrea Maddox, DVM to treat my animal with Animal Chiropractic.  I certify that my animal has had routine, traditional veterinary care, and my current veterinarian is:

Veterinarian:_________________________________ Phone #: (____)  ___________

           Address:_______________________________________________________________

I certify that I have been open and honest with Dr. Maddox as to any and all other examinations, diagnostic tests, diagnoses, and treatments for my animal's conditions.  I have read this authorization form, understand it, and give my consent to examine and treat:

Patient (Animal's) Name:_________________ Breed:________________ Age:__________

Owner'sName:________________Phone:Day_____________Evening_________________

Address:_______________________________ City, State, Zip:_______________________

Animal's Location:_______________________Trainer:__________Phone:_____________

Signed:_____________________________________________________Date:___________