Authorization for Treatment (Revision 3-2012)
Natural Holistic Health Care
751 Northeast 168 Street - North Miami Beach, FL 33162
(305) 652‑5372 – Voice - (305) 653‑7244 – Fax
Click Here To Sign and Submit Electronic Version
PLEASE READ COMPLETELY and RETURN – WE CANNOT START YOUR FILE UNTIL WE RECEIVE THIS FORM!
We charge a $35 non-refundable fee when your file is processed into our system. You will get FULL CREDIT for that $35 on your initial invoice or visit. Please fill in completely and fax it to 305-653-7244 or we can also send an electronic version that can be filled out on the computer, IPhone, IPad or other mobile device, signed electronically and returned SECURELY via Echosign.
We are honored that you are willing to trust us with the care of your animal. As you are likely already aware from reading our material, 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, nutritional and energy related 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 often be used to treat the same broad range of problems that are conventionally treated with drugs.
However, not every problem can be successfully treated in this way. 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 medicine, holistic or otherwise.
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 prefer use these methods as our primary modalities for treatment. If it becomes your decision to have conventional drug therapy or surgery, we may refer you to another practice that can provide this or may elect to provide it ourselves. If it is our opinion that, for the well‑being of your animal, care should be administered by another practitioner or by other methods, than we provide, we may also refer you for this care. What we do is very specialized and may not be the conventional methods of care for these conditions. By signing below, you agree that you clearly understand and agree that this is the direction you are choosing for your animal(s) with our practice.
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.
If you would prefer to sign this and send it to us electronically, the link below these instruction.
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 (20 minutes for phone consultations and 50 minutes plus office exam fee for in office consults). The charges are based on time spent on my case (directly, reviewing files, records, emails, fax reports, research time, and analyzing the case or consulting with a 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 (on a confidential basis) or monitored for quality control purposes to better help my animal.
IMPORTANT - I also understand and agree to the$35 processing charge to cover time and expense for creating my file. This fee is NON-REFUNDABLE but the entire $35 WILL BE CREDITED TO MY FIRST APPOINTMENT INVOICE.
Name (type or print): Date:
Credit Card #: Expiration: Security Code:
Name On Card:
(Actual or electronic)
will take you to a new page where you should press the green start button,
then fill out the required information and then click on the e-sign nad sign in BOTH places. It wil ask for you to confirm your email and send you an email verification for security pourposes. Once you verify the form, it will be sent to us securely and you do not need to worry about printig and faxing it
Click Here To Sign and Submit Electronic Version