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| Issues > Policy > Waiver of treatments |
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| AVMA policy |
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| Waiver of Treatment(s) or Test(s) Form |
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(Approved by the Executive Board April 2006)
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Waiver of Treatment(s) or Test(s) Form
Owner/Authorized Agent: _______________________________________________________________________
Address: ____________________________________________________________________________________
Patient Name: ___________________________ Species: ____________________________________________
Breed: _______________________________ Date of Birth:___________________________________________
Sex: __________________________ Color/Description:______________________________________________
Treatment(s) or Test(s) Recommended:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Waiver of Treatment(s) or Test(s) Statement:
As owner or authorized agent of the owner of the animal described above, I have decided not to proceed with the treatment(s) or test(s) recommended above. The reasons for the procedures have been fully explained to me as well as the risks inherent in not proceeding with them. In making this decision I agree to absolve the (Practice Name) and the staff employed by the practice of any responsibility for the consequences of this decision. I have read and understand this waiver and I am over the age of eighteen.
Signature of Owner/Authorized Agent: _______________________________________
Date: ___________________
Witness: _____________________________________________ Date: ____________________
I certify that if I am signing as an agent, I have the authority to execute this consent.
Name: ___________________________________________________________
(Please print name)
Signed: ___________________________________________________________
Signature of Authorized Agent
Date: _____________________________________________________________
Notes for Potential Users of the Waiver of Treatment or Test Form:
(Not to be printed as part of the form)
- This model form for Waiver of Treatment or Test can be used for those select situations when a difficult client, whose actions or points of view, might put a practice at risk of liability.
- Although no exculpatory language creates a perfect legal defense, the routine use of this form helps build a valid legal defense while providing a psychological deterrent to the filing of a frivolous lawsuit and serves as a form of client education. This form will not relieve the veterinarian of liability for fraud, intentional acts, wanton conduct toward injured parties, or gross negligence. Legal council should always be secured before implementing any forms as part of clinic policy.
- The description of the treatment or tests should be brief but in sufficiently comprehensive detail.
- When more than one veterinarian is involved in the practice, the name of the hospital or clinic should be shown as well as the name of the individual veterinarian. If the number of veterinarians in a clinic or hospital is few enough to make it practical, all waivers should include not only the hospital or clinic name and the name of the individual veterinarian, but also the names of other veterinarians practicing in the clinic as partners or otherwise.
- Where appropriate, such information should be preprinted.
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American Veterinary Medical Association
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