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Against Medical Advice Form

Patient's Full Name(Required)

Client's Full Name(Required)

Client's Phone Number(Required)

Client's Email Address(Required)

Prescribing/diagnosing Veterinarian's name(Required)

The Veterinarian noted above has recommended bloodwork, method of treatment, or means of diagnosing a medical condition. The Veterinarian believes the recommendations stated are in the animal’s best interest.

The recommendation(s) being made for the patient noted above include the following(Required)

At this time, I decline to follow the recommendations noted above. I understand the risks involved in proceeding without following the recommendations by my veterinarian and veterinary medical staff. I release Appanasha Pet Clinic and all of it's staff from any and all liability or medical claims which may result from my refusal to follow these recommendations.(Required)

I decline the recommendations noted above.

Signature(Required)

Phone

This field is for validation purposes and should be left unchanged.