Small Animal New Patient Form

I, , owner of the animal described below and being 18 years of age or older do understand, substantiate and authorize the following:

1. Dr. Ginette St.Pierre is a Doctor of Chiropractic, licensed in the chiropractic care of humans and animals. She has attended several hundred hours of education specific to animal chiropractic and is a member of the College of Animal Chiropractors.

2. I understand that Dr. Ginette is NOT a veterinarian and cannot take responsibility for the primary health care of my animal.

3. I also understand that chiropractic care is NOT intended to replace appropriate veterinary care, but is to be used concurrently.

4. Dr. Ginette has explained the scope of her care, and described the procedures she will perform on my animal. I understand them and acknowledge that they agree with the College of Chiropractors of Ontario’s Standard of Practice for Chiropractic Care of Animals.

* I hereby authorize Dr. Ginette to adjust and treat my animal with animal chiropractic care. I certify that my animal has had regular veterinary care and is concurrently being treated by:

Veterinarian

I certify that I have been open and honest with Dr. Ginette as to any and all other examinations, diagnostic tests, diagnoses and treatments for my animal’s conditions.

I have read and understand the Animal Clinic Policies and give my authorization for care and consent.