ࡱ> JLIM :%bjbj== "HWW !l(((8`|4#""""""""$$ "&""""":!," I (+" ""0#5"R&0&"JILL ELLIOT, DVM, MSW, LLC NY Holistic Veterinarian at Heart of Chelsea Animal Hospital 257 West 18th Street (corner 8th Avenue) New York, New York 10011 Telephone: 212-741-4000; Fax: 212-924-9741 The highest ideal of therapy is to restore health rapidly, gently, permanently; to remove and destroy the whole disease in the shortest, surest, least harmful way, according to clearly comprehensive principles. Samuel Hahnemann, M.D. Aph. 2 Organon of Medicine CLIENT ACCEPTANCE FORM (FORM #10107) WE WANT TO ACKNOWLEDGE YOU for having an open mind and for looking into holistic treatment for your beloved furry family member. To get to this point you have embarked on a journey of exploration and re-education. Thank you for taking that giant step into a new and not to easy to understand but highly effective, time honored treatment modality. Now lets get to work restoring your pet to health. OUR PRACTICE OF MEDICINE provides a very different experience from conventional veterinary medicine. Classical Homeopathy can be used to treat a broader range of problems than those treated conventionally. However, this modality is not magic. Like conventional medicine, it cannot resolve every problem successfully. CLASSICAL HOMEOPATHY, nutrition, and natural supplements will be used as the primary basis for the first line of treatment for your pets problems regardless of the diagnosis, prognosis or conventional protocol for treatment. Some conventional treatments may be employed. HOMEOPATHIC MEDICINES What are they made of? The substances used in homeopathic remedies are derived from plant, mineral and animal sources. When properly prepared, these substances acquire the ability to heal gently without any side effects. All homeopathic medicines are approved by the FDA and are safe for all humans, babies and animals. Office Primary Location (and others) and Hours: Dr. Elliots office is at the Heart of Chelsea Animal Hospital, 257 West 18th Street (corner 8th Avenue), New York, New York. She sees patients at this location Monday, and Wednesday 9:00 am 5:00 pm by appointment only. On Tuesdays and Thursdays from 9:00 am 5:30 pm appointments can be made to see Dr. Elliot at Holistic Pet Care located at 125 Patterson Avenue in Little Falls, NJ Dr. Elliot also works as a conventional veterinarian on Fridays and Saturdays at a practice on the Upper East Side. She can see patients at this office (227 East 84th Street, between 2nd and 3rd Avenues) by special appointments only. To make an appointment to see Dr. Elliot at any location, please call her at 212-741-4000. Please DO NOT CALL THESE OTHER OFFICES TO MAKE AN APPOINTMENT DIRECTLY. If you do this, you may not get to see Dr. Elliot at all or she may not be prepared to see you there. Cost of Services: Our consultation fees for initial Intake Visit: $375.00. The first in-office visit usually runs one hour. This fee also includes time spent doing a comprehensive homeopathic computer analysis of your animals case before, during or after your intake appointment. The first remedy if in pellets/envelope (not liquid form) is free whether given in the office or mailed to you afterwards. After the first remedy, there is a dispending fee for additional remedies. First remedy if pellets: no charge First remedy if liquid in 1 oz. Bottle with dropper: $40.00 The time between follow up appointments is three to eight weeks, depending on the severity of the case. In acute cases, follow-up appointments will be more frequent. FEES FOR DISPENSING REMEDIES (after the first visit) Envelopes$20.00/ per envelope Liquid (LM potencies and other potencies) One ounce bottle with dropper$40.00/ per bottle PAYMENTS ACCEPTED BY: MasterCard, Visa, Amex, Checks and Cash. Fees for Homeopathic Consultations/Intakes on the Telephone/without an office visit: Fees: One half 30 minute intake call: $175; 45 minute intake call: $265.00. Includes fees for computer/case analysis. Telephone only intake consultations for homeopathic treatment are available for pets with special circumstances, i.e., pets that cannot travel, live out of town/state, owner cannot travel due to special circumstances, etc. (An office intake is always preferable for the first consultation. After the initial office visit, telephone follow-up appointments can be arranged to discuss animals response to homeopathic treatment.) Fees will be pro-rated based on time spent on telephone. FEES FOR TELEPHONE CONSULTATIONS/FOLLOW-UPS: Fees for follow-up calls: During regular working hours: (Monday through Friday: 9:00 AM 8:00 PM; Saturday: 9:00 AM 6 PM) 5 Minute call.$30.00 10 Minute call..$60.00 Fees for Emergency Calls after regular office hour calls: (Monday through Friday: before 9:00AM or after 8:00 PM; Saturday: before 9:00AM or after 6:00 PM; Sunday/holiday; anytime): 5 Minute call$40.00 10 Minute call.$70.00 FEES FOR IN-OFFICE EXAM/RE-CHECK AFTER INITIAL INTAKE: $85.00 FEES FOR HEALTHY PET IN-OFFICE EXAM (WELLNESS EXAMS): $85.00 NOTE: If your pet is showing any signs of illness that concerns you, PLEASE CALL DURING NORMAL BUSINESS HOURS TO SPEAK WITH DR. ELLIOT. THIS WILL ALLOW US TO PROVIDE THE BEST SERVICE TO YOU AND FOR YOUR PET. YOU WILL HAVE THE MOST OPTIONS FOR CARE. No calls will be returned after 8:00 PM unless it is an emergency. To best service you we require at least 24 hours cancellation notice. To reschedule or cancel an appointment please call the main phone number only 212-741-4000. There is a twenty-five dollar ($25.00) fee for returned checks. WHAT YOU CAN DO TO ASSIST IN THE PROCESS OF YOUR PETS CARE: 1. Monitor your pet well and keep good records. This is essential. You are an active member of your pets treatment team. The decisions made at each point in the treatment depend on your accurate observations, and, our degree of success depends on this. PLEASE DO NOT ADMINISTER OR DISCONTINUE ANY MEDICATIONS OR SUPPLEMENTS WITHOUT CONSULTING WITH US FIRST. THIS INCLUDES ALL SERVICES OFFERED BY YOUR LOCAL/CONVENTIONAL VETERINARIAN FOR ROUTINE MATTERS AND EMERGENCIES. Be on time for all appointments to help us keep on schedule. Please bring the following to the first appointment (if possible): ( A photo of your pet. ( A brief record from a recent veterinary exam (if possible) indicating a diagnosis. ( Any recent test results (blood work, urine analysis, and ultrasound report if done, etc.). ( X-rays, pertinent to the case (if available). ( A list of all medications and supplements currently being taken. ( A list of all homeopathic medications given in the past (with dates and doses) if applicable. ( Last date of vaccinations and list of which were given. We prefer that you bring this information with you to your first appointment; if you have a telephone consultation mail OR fax (212-924-9741) them to us at least one day prior to the office visit. Please do not mail X-rays. Please fill out one copy of the Declaration of Acceptance below. Bring it with you to our first visit COMPLETELY FILLED OUT to save time. JILL ELLIOT, DVM, MSW, LLC NY Holistic Veterinarian c/o Heart of Chelsea Animal Hospital 257 West 18th Street (corner 8th Avenue) New York, New York 10011 Telephone: 212-741-4000; Fax: 212-924-9741 DECLARATION OF ACCEPTANCE I have read and understand the four-page Client Acceptance Form (Form #10107). I agree that I want Classical Homeopathy to be used to treat my pet(s). I further state that I am not expecting any other treatment than what is described here. NAME (Please print):_________________________PETS NAME(S):_____________ CLIENT SIGNATURE:__________________________________DATE:__________ I authorize the use of my credit card (Visa, MasterCard or American Express) by Dr. Elliot over the phone: Card Number: _____________________________________________ Expiration Date: ___________________________________________ Name as it appears on card: __________________________________ _______I authorize Dr. Elliot charging my credit card directly after telephone follow-up appointments or for other services. Signature: ______________________________________ Please be sure to sign this form in both places. Thank you. Please bring this with you to the first appointment or one day prior to your appointment, fax this sheet back to Dr. Elliot at 212-924-9741. Thank you. 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