Informed Consent
for Veterinary
Supervised Behavior Medicine
Pet’s
name: ________________________ Sex: _________ Age:
____
Owner name:
______________________________________________
Owner
address: _____________________________________________
Telephone: _________________________________________________
I, the undersigned, being the owner or duly authorized
agent for the owner of the above animal, understand that the drug prescribed
for my pet has not been approved for use in dogs or cats based on drug
company trials in this species.
I have been advised that the drug is being used on an
extra label basis and I accept the consequences of its use. I will not hold
the veterinarian, staff or related parties responsible for any adverse
effects, be they physical or behavioral, that might arise out of the use of
this drug.
I have been advised of the potential side-effects and
adverse effects of the medication, such as: and will discontinue the
use of the drug and contact my veterinarian or the after hours emergency
hospital immediately should any adverse or unexpected effects be exhibited.
I understand that laboratory tests need to be
performed prior to drug use, and if I waive those tests, I am assuming the
additional liability. I understand that these tests should be repeated at
intervals to be determined by the veterinarian, based on the specifics of
the case.
I understand that this drug may not alter and even
temporarily worsen the course of the behavioral problem, and that my animal
may continue with the problem behavior and may injure itself, other animals
or other people.
I hereby give my informed consent to the
administration of this drug to my animal. I accept full responsibility,
legal and financial for all actions that may occur from the use of this
drug.
Signed:________________________________
Date: ____________
Witness:_______________________________
Date: ____________