Against Medical Advice Release

Client Information

Address

Patient Information

Is your pet spayed/neutered?
MM slash DD slash YYYY

I, the undersigned owner or authorized agent for the owner of the above mentioned patient, hereby acknowledge that, because of the serious or fragile medical condition of my pet, the doctor(s) at Veterinary Specialists of the Rockies are recommending that he/she be hospitalized for further diagnostic procedures, nursing care, surgery, and/or treatment. In spite of the nature of his/her condition, I am requesting that my pet be released and discharged to me. I fully recognize that this release is against the attending doctor’s recommendations.

I understand that the above mentioned patient requires further medical attention and that it is my responsibility to seek such care at the veterinary facility of my choice. In the event any adverse medical problems (including death) occur because of my decision to remove my pet from this facility, I accept full financial and medical responsibility for my decision and hereby release Veterinary Specialists of the Rockies, its staff, and contracted agents from all responsibility and liability for that choice.