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Becoming a Pet-Centered Practice

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:   ____________

[1] Adapted from a form developed by Gary Landsberg, DVM DACVB

...::::::: Copyright 2000-2009 Rolan Tripp, DVM :::::::...