Authorization For Treatment (Revision 5-2008) Natural Holistic Health Care 751 Northeast 168 Street North Miami Beach, FL 33162 (305) 6525372 – Voice - (305) 6537244 – Fax PLEASE READ COMPLETELY – We charge a $35 non-refundable processing fee when your appointment is scheduled. You will get FULL CREDIT for that $35 on your initial invoice or visit. We are honored that you are willing to trust us with the care of your animal. As you are likely already aware, our practice is not the usual. What we offer in terms of treatment is the use of homeopathic medicines, Traditional Chinese Medicine (Acupuncture, Moxabustion and Herbs), Chiropractic and nutritional therapy. We emphasize these forms of treatment because we feel that these are the most effective ways of dealing with a wide variety of health problems that animals face. It is our opinion that these regimens can be used to treat the same broad range of problems that are conventionally treated with drugs. It is also our experience that holistic medicine can be a very successful approach to health care. However, not every problem can be successfully treated by us. Many clients find us because conventional veterinary medicine has left them without hope of any solution, so we are often faced with very serious cases. Sometimes, the level of disease is too far advanced for even our methods. At other times, we may not possess the necessary knowledge or experience for success and, occasionally, our methods fail despite of our best efforts. We say this not to discourage you, but rather to honestly communicate possible limitations in this form of medicine. It is important, as we start working together, that you realize, regardless of the nature of the problem your animal has and, in spite of the diagnosis or prognosis that you have received from another practitioner, we are going to use the abovementioned methods and no other in the treatment of your animal. If it becomes your decision to have conventional drug therapy or surgery, we will refer you to another practice that can provide this rather than do this ourselves. If it is our opinion that for the wellbeing of your pet you should receive care from another practitioner or by other methods we will also refer you for this care rather than provide it ourselves, Due to the nature of our practice and the amount of time we must dedicate to each case, it is difficult for us to handle more than a limited number of emergencies and you should not expect us to be available on a 24-hour basis. We take a limited number of patients and try to give them very personalized service, but suggest that, should a life threatening emergency occur AND WE CANNOT BE REACHED IN A TIMELY FASHION, you use an emergency facility to preserve your pet's life and we will worry about the after care once the situation is stable. This is not to say we are never around, only to make sure you understand what we suggest if we are not available at that time. Declaration of Acceptance I have read the above explanation of the type of treatment offered by Natural Holistic Health Care. I understand their methods of treatment and agree that this is what I want for my animal. I further state that I am not expecting any other treatment than what is described here and agree to abide by the conditions set forth in this authorization. I also confirm that I have read and understand the required items (Consultation Guide and Primer), have been informed of the standard charges and missed appointment policy (24 hours notice or we have the option of charging our minimum (15 minutes for phone consultations and 30 for in office consults). These charges are based on time spent on my case (either directly, analyzing the case or consulting with my referring veterinarian), and for materials and items dispensed or mailed. I authorize them to charge my credit card for these services and any supplies and missed appointments (at their discretion). I also understand and agree that consultations may be recorded or monitored for quality control purposes to better help my animal. IMPORTANT - I also understand and agree to $35 processing charge to cover time and expense for creating my file. This $35 Processing fee is NON-REFUNDABLE but the entire $35 WILL BE CREDITED TO MY FIRST APPOINTMENT INVOICE. Name: (print) Credit Card Number Signature: Expiration Security Code Date Name on Card Contact Phone: Email: