Prescription Policy Waiver

Waiver of Responsibility and Liability for Prescriptions to be Filled by Internet Pharmacies, Catalog Vendors, or Non-Veterinary Pharmacies

For additional information regarding the form, the veterinary services we provide, appointments, or for other general questions, please contact our office during business hours.

For use before the first prescription clients request to pursue internet, catalog purchases, or non-veterinary pharmacies. This document will remain in effect until canceled by the client, in writing.

Pet's Name*

Today's Date*

I hereby request a prescription for medication(s) for my pet so that I can purchase these products from an internet pharmacy, catalog vendor, or non-veterinary (human) pharmacy. (Please Initial)

I have been informed that the following risks exist when I obtain these products from such sources. There is the possibility that the prescription drugs received from these vendors may be counterfeit and may not have been approved by the FDA; the vaccines may not have been approved by the USDA; and the pesticides may not have been approved by the EPA. This has occurred in the past and could recur. (Please Initial)

As the provider of your pet’s care, our medical records keep track of all drugs dispensed by us to you. When you purchase your pet's prescriptions elsewhere, our computer tracking system is not activated to print instructions for use or risks of adverse effects or to send reminders for follow-up exams and/or lab tests that may be needed to monitor results or adverse reactions. You may not have the prescription drug(s) available soon enough to start your pet’s medications at the optimal time to provide relief for his/her condition. When prescription products are purchased elsewhere, our staff members are unavailable to teach you how to administer them. The number of tablets or capsules, milligram size of the unit, volume and/or concentration of liquid, and number of authorized refills may differ from that prescribed by the attending doctor. Manufacturer rebates that would ordinarily be available for products purchased from this facility generally will not be available. (Please Initial)

The manufacturer’s warranties or guarantees for these products may not be valid. This means if your pet’s condition is not effectively treated with the product(s), manufacturers may not stand behind their products or product liability procedures. Additionally, the owners and doctors at this facility will be unable to assist you in claims against those manufacturers. (Please Initial)

I have read and understand the above, I accept these risks, and I am aware that this facility cannot accept any financial responsibility for paying for or reimbursing me for any treatments required as a result of the use of products purchased from these outside sources. In the absence of negligence, I agree to hold this veterinary practice harmless for any deleterious effects or lack of effectiveness of drugs purchased from any other source. (please Initial)

*Any original written prescriptions will be required to be returned to us to dispense the same medication at our facility. This helps us prevent the unauthorized dispensing of prescription medications.(Please Initial)

Please type your full name below to acknowledge that you have read the above policy and accept the risks of purchasing prescriptions from outside sources. **

I acknowledge that my digital signature stands in for my handwritten signature.