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 and treat my pet with 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 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. 

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


[Please Sign Here:] ________________________________________________________________
Owner or Responsible Party