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Client Information and Release Form

Welcome!  Thank you for the honor of working with you and your pet.  We trust you look forward to the exciting teamwork ahead as we do.  The information on this page will help establish guidelines and expectations and prevent misunderstandings.  Please read it carefully and feel free to bring any comments or questions to your appointment.

You must agree to these terms with your signature on the release form is at the bottom of this page.

Eugene Simkins, patientPROTOCOL AND FEE STRUCTURE

If you are like most of us, one of the first things you want to know is how all this works and the fee structure.  So, since we are all thinking of helping your loved one as the most important thing, let's set up the foundation for our teamwork to make it easier for you to plan, and to assist in the process.


Our practice differs
from the usual veterinary office in that the main service we provide is our expertise rather than products like pills and ointments, or services like surgery and radiographs.  For these services you will be referred back to your local/conventional veterinarian as needed.  Our consultation fees are based on an hourly rate for the time spent working on the case.  This includes time spent evaluating medical records, radiographs, laboratory data; consulting with other veterinarians, including your conventional veterinarian (if necessary); in-office and telephone consultations; and all time spent on case analysis after the consultation (this is often the most important effort we put into your case).


Time is assessed in five-minute increments or fractions thereof, starting at your scheduled time.  We trust you understand that our sincere effort to serve all of our patients and clients as best we can sometimes alters our schedule.

The first appointment
is quite extensive, running an average of forty-five to ninety minutes, and the average total cost is two to four hundred dollars.  Care for complicated cases or those with severe pathology such as cancer cases will increase this range.  Following appointments generally last 10 - 20 minutes and average forty to eighty dollars.  The time between appointments is usually three weeks to three months, or more frequently in acute states.  The total length of time needed to treat most chronic disease cases is two months to one year, depending on the difficulty of the case.
We have a one time, nonrefundable clerical fee of thirty dollars which gets you set up as a client.  There is a missed appointment fee of twenty-five dollars.  We require at least twenty-four hours notice for appointment cancellation so that we may schedule another client.  This helps us to better serve new clients with severely ill pets who may be waiting several weeks for their first appointment.  There is a twenty-dollar fee for returned cheques.  Emergency (unscheduled or after hours) consultations are charged a forty-five dollar fee.  Our additional fees are laid out in more detail on our fee schedule.

We take payment
in the form of credit card (Visa or MasterCard) for phone consults.  For in-clinic appointments credit card, cheque, or cash are accepted.

Our practice of medicine provides a very different experience from conventional veterinary medicine and it is our opinion that this form of therapy can be used to treat a broader range of problems than those treated conventionally. However, the medical modality we use is not magic. Like conventional medicine it cannot resolve every problem successfully. You can, however, expect the following:

  • Our very best effort in treating your pet.
  • A firm commitment to continually advance our skills and our services.
  • Our most accurate prognosis for your pet at the end of the first appointment.
  • Virtually 100% emergency coverage by us or by another qualified homeopathic veterinarian.
  • Case treatment coordination with your local/conventional veterinarian.
  • Consultation for second opinions or referral to other homeopathic or conventional veterinarians as we see fit for the best care of your pet.
  • Classical Hahnemannian Homeopathy, nutrition, and natural supplements as the primary basis for treatment regardless of the nature of your pet's problems or the conventional diagnosis, prognosis, or usual protocol for treatment.

Your responsibilities are as follows:

1.     Monitor your pet well and keep good notes. This is essential. The treatment decisions made at each appointment and, therefore, our degree of success depends on this.

2.      Help coordinate treatment between your local/conventional veterinarian and us openly and honestly. We look forward to working with your local veterinarian. We must all work as a team for the good of your loved one. After all, medicine is a service profession. We are all here to serve you and your pet.

3.      While we strongly encourage you to actively participate in the decisions in your pet's case, please do not administer nor discontinue any medications or supplements without consulting us first. This includes all services offered by your local/conventional veterinarian for routine matters and emergencies. This greatly helps to avoid problematic complications. We say this not to discourage you, but to invite you to use our experience in coordinating the use of other modalities with homeopathy correctly, effectively and safely. Again, we eagerly welcome input from you and your local/conventional veterinarian. To help insure a smooth case, just consult us first.

4.      Be on time for appointments to help keep us on schedule.

For your first appointment it is most helpful to have the following information:

o         An account in your own words of your pet's condition and history. Please type or print

neatly using only one side of one page.

o         A brief record from a recent veterinary exam indicating a diagnosis.

o         Any recent test results.

o         A photo of your pet (and you, too, if you like).

o         A list of all medications and supplements currently being used.

We prefer that you bring all of these things with you for your first appointment, or mail them if you have a telephone consultation.  If time is short you may fax your information to 845/338-9875 or email it as a .jpg or .pdf file to info@holvet.net, but please limit the number of pages to ten or less.  Documents must be received two business days in advance of the appointment if Dr. Yasson is to review them prior to the appointment.

Client Release Form:
Name:
 * required
Address:
 * required
City:
 * required
State:
 * required
Zip Code:
 * required
Home phone:
xxx-xxx-xxxx
 * required
Work phone:
xxx-xxx-xxxx ext
Cell phone:
xxx-xxx-xxxx
email address:
Referred by:
Conventional veterinarian:
Phone:
Additional information:
Names of other household members:
Best way to contact you:
I agree.
By checking the box above, I agree that I have read and understand the Client Release Form (Form 101707), covering protocol, fee and payment structure, and type of treatment offered by HolVet.  I agree that this is what I want for my pet.  I further state that I am not expecting any other treatment than what is described here and that HolVet has my permission to charge the fees as described above to the credit card on my account.


I further understand that, should a new version of Client Release Form replace Form 101707, that it will be made available electronically for my review.