"*" indicates required fields Client's Name* First Last Pet's Name* Date* MM slash DD slash YYYY The homeopathic services you have requested are directed at strengthening your pet’s constitution and vitality. They are not directed at identifying, treating, or preventing specific diseases. While Tracy Duffner is a veterinarian licensed in the states of South Carolina and Georgia and a veterinary homeopath, the homeopathic services provided do not constitute diagnosis, prognosis, treatment, administration, or prescription for any disease, pain deformity, defect, injury, wound, physical condition or mental condition requiring medication for any animal or for the prevention of or the testing for the presence of any disease. If you have a medical complaint or question about your pet’s health, you should see a veterinarian. CLIENT ACKNOWLEDGMENTS:I acknowledge that I have the option of seeking/continuing conventional medical care from a licensed veterinarian and that homeopathic treatment and conventional medical treatments are different but can complement each other. I confirm that there has been no suggestion made to me that I refrain from seeking or following conventional medical treatment. I recognize that input from my pet’s veterinarian is welcome, and the information will be used to augment the homeopathic case-taking process. I am free to withdraw my consent and to discontinue treatment at any time. I confirm that any prescription medications my pets are taking under the care of a veterinarian will not be withdrawn without his/her supervision. I fully understand what has been presented to me with regards to the nature of homeopathic medicines and their safety, and the credentials of my homeopath. I understand that a block of time has been set aside for my private appointment, and that a 2-business day notification is required if I must cancel. I understand that there is a full charge for appointments canceled less than 2 business days in advance. I understand that payment is due at the time services are rendered, unless other arrangements have been made prior to the appointment. I understand that phone consultations and emails will be billed at the usual hourly rate. I HAVE CAREFULLY READ THIS AGREEMENT AND AGREE TO THE TERMS OUTLINED ABOVE. I UNDERSTAND THIS AGREEMENT TO BE A FULL AND FINAL RELEASE OF ALL COSTS, CLAIMS, CAUSES OF ACTION AND DAMAGES OF ANY KIND ARISING FROM OR IN CONNECTION WITH THE HOMEOPATHY SERVICES.Client Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
