Authorization for Introductory Call (Revision 12-2013)
Natural Holistic Health Care
751 Northeast 168 Street - North Miami Beach, FL 33162
(305) 652‑5372 – Voice - (305) 653‑7244 –   Fax 

PLEASE READ COMPLETELY and RETURN – WE CANNOT SCHEDULE THIS CALL UNTIL WE RECEIVE THIS FORM! 

We will charge a ONE TIME $60 non-refundable (within 48 hours of scheduled appointment) fee for this service.  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 Docusign. This is available via our website under Clients – Intro Call Authorization. If we move on to an “official” client status there is a second STANDARD authorization we will need from you.

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.

The purpose of this specific call and review of medical records is to help us decide if this course of therapy is an appropriate option for this case and, until additional steps are taken we cannot assume any further responsibility beyond this initial call until we enter into an official relationship..

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 aftercare 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 confirm that I have read and understand that this authorization and agree to the onetime $60 charge for up to 30 minutes of case time to help us decide whether we want to move forward into a client relationship. This time will be used to review medical records, case files, radiographs and to talk with the Doctor on the phone or Skype to help me better understand the case options, prognosis and modalities. The Doctor will not prescribe specifics at that time as but will go over the generalities of my specific case. This fee is refundable up to 48 hours prior to the appointment – after that time or if the appointment is made closer to that 48 hour deadline then it is NON-REFUNDABLE Fee.  The standard office 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. The charge for this specific service is limited to $60 for this special consultation

I authorize them to charge my credit card for $60. 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.

 Name (type or print):									Date:

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Name On Card:

My Signature 
(Actual or electronic)
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