Informed Consent & Financial Policy

Thank you for choosing Dr. Paige for your pet’s chiropractic care.

We are dedicated to providing the finest quality care with the best possible service available. Our financial guidelines are based on an open and honest discussion of our fees. Please read and sign this document.

Informed Consent

Date

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Mobile Phone

Email *

Patient's Name

Age

Sex

Type of Animal (i.e. horse, dog)

Breed

Reason for Visit, Chief Complaint or Wellness Visit:

Who referred you to Dr Paige?

Chiropractic health care seeks to restore health through natural means without the use of medicine or surgery. This gives the body maximum opportunity to utilize its inherent recuperative powers. The success of the chiropractic doctor’s procedures often depends on environment, underlying causes, physical and spinal conditions. It is important to understand what to expect from chiropractic health care service.

I have had an opportunity to discuss with Dr. Jessica Paige the nature and purpose of chiropractic adjustments and procedures. I understand and I am informed that, as is with all healthcare treatments, results are not guaranteed and there is no promise to cure. I further understand and I am informed that, as is with all healthcare treatments, in the practice of chiropractic there are some risks to treatment, including, but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. *

I have read and understand.

I further understand that chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxations allowing the animals body to return to improved health. It can also alleviate certain symptoms through a conservative approach with hopes to avoid more invasive procedures. However, like all other health modalities, results are not guaranteed and there is no promise to cure. *

I have read and understand.

I certify that my animal(s) have been referred for chiropractic care to Dr. Jessica Paige by my veterinarian and that my animal(s) have been continuing to receive concurrent care from my veterinarian. (Dr. Paige has had specialty training in the chiropractic care of animals. Dr. Paige is NOT a veterinarian and cannot take responsibility for the primary care of your animal). *

I have read and understand.

Name of Veterinarian

Cell Phone (equine) or clinic name (canine/feline)

I am the owner/caretaker of the animal named herein acknowledge that I approve the use of chiropractic adjustments for the above named animal. *

I have read and understand.

Financial Policy

Payment: We accept Cash, Checks, Visa and MasterCard. Payment for treatment are due AT THE TIME SERVICES are rendered. *

I have read and understand.

Missed Appointments: Your pets appointment time has been reserved specifically for them. If you choose to CANCEL or RESCHEDULE an appointment with LESS THAN 24 hours notice, by phone, text or email, or if you fail to appear for an appointment, you will be CHARGED $85 for that appointment. We cannot make special circumstances for every individual therefore the policy pertains to all owners. *

I have read and understand.

Late Arrival For the Appointment: The office strives to maintain a punctual schedule. If you arrive 15 minutes or more after your scheduled appointment time, we CANNOT guarantee you will be seen at that time. You will be rescheduled according to availability and subject to the 24 hour missed appointment policy. *

I have read and understand.

I, the undersigned, have read the above financial guidelines, and agree to abide by these policies. *

I have read and understand.

Signature *

Clear Signature

Date *

Do you already have an appointment scheduled? *

If so, when? *

Date

Time

Would you like us to contact you to schedule one? *

Comment

Contact

Phone: 925-380-1888
Email: [email protected]

Location

3128 Santa Rita Road, Suite B
Pleasanton, CA 94566

Hours

Mon - Fri: 7:30 am - 6:00 pm
Sat - Sun: Closed

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