Prescription Waiver Form – Kensington Bird & Animal Hospital

Waiver of Responsibilty and Liability for Prescriptions to be Filled by Outside Internet Pharmacies Not Associated with This Hospital
Client's Name*
First Last
Pet's Name*
*
- I hereby request a prescription for medication(s) for my pet so that I can purchase these products from an outside internet pharmacy not associated with this hospital. By signing this waver, I acknowledge that I have been properly informed of the risks involved in doing so, and accept any and all responsibility, financial or otherwise, that may occur from this decision. I understand that this hospital will be held harmless from the use of products and/or prescriptions purchased from sources outside of the hospital's monitoring and control.
  Risks involved in purchasing pharmaceuticals or food products for my pet over the internet:
  1. There is no way for my veterinarian to know if the product has been stored properly while in transit, is out of date, repackaged or counterfeit when purchased from and outside internet source. This has occurred in the past. For more information on this, visit the FDA website at www.fda.gov.
  2. The prescribing instructions for products purchased from other sources may be different from those recommended by my veterinarian. This could result in improper dosing of my pet.
  3. Purchases from outside on-line pharmacies may not appear in my pet's medical records provided by my veterinarian. This information may be important in the event that my pet needs additional medications and/or treatment from my veterinarian.
  4. Product warranties for prescriptions obtained from outside internet pharmacies may be different than the manufacturer's normal warranties or potentially unavailable. It is understood that my veterinarian is unable to offer warranties for products or prescriptions obtained through outside sources.
  5. The prescription and/or its refills may not arrive in a timely fashion, thus potentially causing an interruption in treatment for my pet, which may result in the need for additional testing prior to the continued safe use of the product.
Consent*
I have read and understand the above risks in using an outside internet pharmacy that is not associated with this veterinary hospital.
Consent*
I am 18 years old or older
Name of Client or Authorized Agent*
Date*
Date Format: MM slash DD slash YYYY

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Waiver of Responsibilty and Liability for Prescriptions to be Filled by Outside Internet Pharmacies Not Associated with This Hospital

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