Hold Harmless Waiver of Treatment Agreement

Hold Harmless Waiver

Please complete the following information. All entries are required. You will be redirected to an electronic signature gathering site upon completion of this form.

Today's Date*
MM slash DD slash YYYY
Name (Primary Guardian and Contact)*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Pet's Name*
Pet's Name
Species*
Please select your pet's species.
Age*

Please enter your pet's age.
Pet's Breed*

Please enter your pet's age. You may approximate if birth date is unknown.
Waiver Request*
Please describe the service or medication that has been recommended to you by your attending DVM for which you are requesting a waiver.

Hold Harmless Waiver of Treatment Agreement

Hold Harmless Waiver

Contact Information