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Against Medical Advice Form

Please read the following form carefully and complete all fields as accurately as possible. If you have any questions before signing, we encourage you to speak with your veterinarian or a member of our team.

Against Medical Advice

Contact Name *

First

Last

Contact Phone Number *

Contact Email Address *

Contact Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet Name *

Pet Birthdate *

Pet Species *

Pet Breed *

Pet Sex *

This is to certify that I, the owner of this pet, choose to go against the medical advice of the staff and veterinarians at Dogwood Veterinary Clinic. A veterinarian or technician has explained to me the risks associated with refusing this medical advice. I understand those risks may have adverse side effects up to and including death of the patient. Although I have been made aware of this, it is still my decision to refuse the advice of the staff and veterinarians at Dogwood Veterinary Clinic. I hereby release Dogwood Veterinary Clinic, its veterinarians and staff, from any liability or medical claims resulting from my refusal of the medical advice provided. * *

I agree

Client Signature *

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Date *

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Against Medical Advice Form

Against Medical Advice

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