Owners Name___________________________ Date__________________________

Address______________________________________________________________

Number to be reached at_________________________________________________

Animal’s Name ________________________________________________________

Species_________________________ Breed _______________ Color ___________

Age____________________________ Sex _________________ Weight __________


I, [Please Print Your Name Here:] ______________________________being responsible for the above described animal, have the authority to grant you my consent to receive, prescribe for, treat and/or operate upon my pet. I understand the surgery or treatment to be performed is:
____________________________________________________________________  
____________________________________________________________________ 
____________________________________________________________________ 
____________________________________________________________________ 

Anesthesia drugs that may be used include Drug Name_________________________________________

I understand that the use of the medication, described in the attached VETERINARY PHARMACEUTICAL DATA SHEET, in the treatment of my animal constitutes off label use. This is defined as “actual or intended use of a drug in a manner that is not in accordance with the approved labeling” and is used in this instance to either describe the use in a species not listed in the labeling or for indications not listed in the labeling. Many human approved drugs are commonly used in veterinary medicine that have not been approved for use in veterinary patients but for which no species approved product is available. 

[Initial Here:] ________________ I have read the attached VETERINARY PHARMACEUTICAL DATA SHEET which contains specific drug related precautions and potential side effects. I realize that the VETERINARY PHARMACEUTICAL DATA SHEET provided to me is provided as a baseline reference to help alert me to issues relating to this drug and I realize that there may be other precautions and/or potential side effects that are either not known or listed at this time.

You are to use all reasonable precautions against injury, escape or death of my pet, but you will not be held liable or responsible in any manner in connection therewith as it is thoroughly understood that I assume all risks. 

I understand that there may be times when my pet will be left unattended in the hospital.

I understand that I assume financial responsibility for all services rendered, and that payment is due on the date of the surgery. If the pet is not called for within a 3 day period, the animal will be considered abandoned and appropriate measures to secure long term placement of the animal will be sought as the doctor sees fit. It is understood that this does not relieve me from paying for all costs of your services and use of your hospital including the cost of boarding.

After carefully reading the above, I have signed in agreement.

[Please Sign Here:] ________________________________________________________________
Owner or Responsible Party