OUTSIDE CONTROLLED SUBSTANCE WAIVER

Hospital Name

Client Name

Pet Name

Outside Controlled Substance Medication

Prescribing Doctor

Prescribing Doctor Phone

Dispensing Pharmacy

Dispensing Pharmacy Phone

The client hereby confirms and acknowledges each of the following:

1. The client is the owner of the pet;

2. The pet requires the medication to treat a medical condition;

3. The medication was prescribed by the prescribing doctor;

4. Doses of the medication cannot be missed for my pet's medical condition and my pet needs to receive the medication while in the care of the hospital;

5. The medication is a controlled substance and, accordingly, the possession and use of the medication are regulated by federal, state and/or local laws, rules and regulations;

6. Since the hospital does not carry the medication, the client has provided the medication to the hospital and directed the hospital to administer the medication in accordance with the label affixed to the medication by the dispensing pharmacy;

7. The medication was prescribed by the prescribing doctor and dispensed by the dispensing pharmacy; and

8. There are inherent risks and side effects associated with the use of the medication and potential side effects including without limitation: sedation, disorientation, a rise or drop in blood pressure, heart rate, temperature, respiratory rate, unexpected interactions from stress of hospitalization and death; each of which risks and side effects have been fully described to me by the prescribing doctor.

9. If, after administering the Medication, there is an adverse reaction, | give my permission to the Hospital to provide any treatment the Hospital deems necessary for immediate care. I agree to be responsible for payment of any and all medical services rendered.

If the Hospital is directed to administer the Medication in any manner different from the instructions on the label affixed to the Medication by the Dispensing Pharmacy, please explain what they are and why the instructions changed

Please list special dispensing or storage instructions that may apply to the Medication

In consideration of the Hospital's agreement to administer the Medication to my Pet as contemplated by this Outside Controlled Substance Waiver, the Client, on behalf of himself/herself and any other owner of the Pet, to the fullest extent permitted by law, does hereby: (i) release the Hospital, its affiliates and their respective officers, employees and agents from any and all injuries, claims, liabilities or damages (collectively, "Losses") which the Client may have or had against the Hospital arising out of, connected with, incidental to, or in any way related to the possession or administration of the Medication to my Pet; and (ii) agree to indemnify, defend, and hold the Hospital harmless from and against any and all Losses arising out of, connected with, incidental to, or in any way related to the possession or administration of the Medication to my Pet.

Printed Name

Signature

Clear

Date

Primary Phone Number

Secondary Phone Number

Name: Emergency Contact

Emergency Contact Phone Number

I hereby acknowledge that the above information provided for the dispensing of medication for my Pet

Printed Name

Signature

Clear