Vet Release - Fraser Valley Chiropractic

Veterinary Orthopedic Manipulation Treatment Release

Pet Name*
Owner Name*
First Last
DVM*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Animal DOB*
MM slash DD slash YYYY
Gender*
- Male
- Female
Breed*
Is your pet on any medication?*
- Yes
- No
Please list the medications your pet is taking*
Has your pet had any surgical procedures?*
- Yes
- No
Please list your pet's surgical history*
Will treatment be performed in the state of Colorado at Fraser Valley Chiropractic, Inc.?*
- Yes
- No
Where will treatment be performed?*
I understand and agree to the following:
1. As with all medical procedures, this technique is being applied without guarantee of cure and promise of relief. In clinical practice, 7-9% of cases do not respond to VOM.
2. The VOM Technology is inherently non-invasive and safe. To date, not animal has been injured with this method of diagnosis and treatment.
3. Like Veterinary Acupuncture was for years, the AVMA still regards veterinary chiropractic techniques as “experimental” in the US. VOM in and of itself is not a chiropractic technique, but would be grouped in this fashion.
4. The undersigned has been advised as to other treatment regimens such as medicine and surgery and has been encouraged to seek a second opinion, or has already done so.
I wish to have the VOM Diagnostic and Treatment Technology applied to my pet.
Your Name*
First Last
Date*
MM slash DD slash YYYY
Signature*
Provider Signature
Dr. Jill M. Hutter D.C. | 345 Zerex St., Unit 3 | Fraser, CO 80442 | P: (970) 363.7156 | jillhutterdc@gmail.com

Veterinary Orthopedic Manipulation Treatment Release

I understand and agree to the following:

I wish to have the VOM Diagnostic and Treatment Technology applied to my pet.

Provider Signature