Client Consent Form

I understand that Dr. Alexia Tsakiris, BVetMed, is a licensed veterinarian who focuses her practice on complementary and holistic therapies including but not limited to: acupuncture, herbal medicine, laser, food therapy, ozone therapy, spinal manipulation, and the understanding of the human-animal bond. *

I agree

I understand that my own participation is essential in helping my pet. This includes but is not limited to providing appropriate social, psychological, hygienic, physical, emotional, spiritual, mental and routine medical care for my pet, as well as myself. I understand and am open to learning more about how my own energy affects that of my pet. *

I agree

I am also responsible for communicating if my pet has aggressive tendencies. I understand that I am responsible for restraining my pet during acupuncture, and if I waive that right I will not be present during the treatment. I understand that a technician or I need to be alert and present so that the needles are not pulled out. *

I agree

I understand that Dr. Tsakiris always maintains her Hippocratic Oath to “above all else do no harm, “ and works with the animals and not against them. This may mean that for some sensitive animals, subtle energetic techniques may be more appropriate than the use of acupuncture needles. *

I agree

I understand that Dr. Tsakiris, always does her best to heal her patients, and there is never a guarantee as to the outcome; as is true with all medicines and all aspects of life. I understand it may take at least 3 consecutive treatments to see how the patient responds. *

I agree

Pertaining to telemedicine, I consent to the use of telemedicine for the care of their animal *

I consent

I understand that payment is due at the time of services rendered, and there is a $40 returned check fee. I understand that if I fail to give 48 hours notice for canceling or changing an appointment, I will be charged a $109 fee for a follow up appointment and $230 for an initial appointment for the disregard of Dr. Tsakiris’s time and that of fellow patients who would have liked that appointment time slot. *

I agree

I understand that 2 followup emails are allotted per visit and I will be charged a fee for email and phone communication associated with the reply to long emails or returned phone calls at the same rate of an appointment, as appointments should be made for situations which involve multiple questions taking over 5 minutes of the doctor's time. * *

I agree

I agree to receiving emails from Dr. Alexia Tsakiris *

I agree

I agree to have a general practitioner veterinarian as I understand that Dr. Tsakiris does not stock conventional medications and is unable to provide advanced diagnostics (such as x-rays). I understand the importance of a team approach for my pet's health. *

I agree

Pertaining to telemedicine, I understand that Dr. Tsakiris has a limited ability and can’t conduct a physical exam via telemedicine and this may create a situation where something is missed, but will do her best and Dr Tsakiris will recommend a referral *

I agree

I understand that I am responsible for submitting insurance forms and claims to my pet insurance company

I agree

I understand the potential risks of telemedicine: include but not limited to limitations of not having a physical exam and illness and conditions may be missed, the info that is transmitted may not be sufficient, lack of medical records may result in an inaccurate diagnosis, may be delays in medical evaluation or treatment due to deficiencies or failures of equipment, information shared may not be sufficient for diagnosis or treatment, illnesses or conditions may not be observe diagnosed or treated, does not allow a physical exam, lack of medical records may result in an inaccurate diagnosis, adverse drug interactions, or allergic reactions, or other medical judgement errors. *

I agree

I understand that my pet needs to be seen by Dr. Tsakiris bi-annually to maintain a doctor-patient relationship. *

I agree

By signing below I authorize Dr. Alexia Tsakiris and their assistants to administer such treatment and or perform such diagnostic procedure as agreed upon, send periodic emails, and to pay my balance in full at the time of services rendered. It is understood that no guarantee or assurance has been made as to the results that may be obtained. I assume full financial responsibility for all charges incurred by my pet(s). *

I agree

Name of Human Guardian *

First Name

Last Name

Today's Date *

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