Happier At Home Mobile Veterinary Hospital
PO Box 89, Bel Air, MD 21014 • info@happierathomevet.com • www.happierathomevet.com
Prescription Waiver
Date
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Month
-
Day
Year
Date
Owner's Name:
*
First Name
Last Name
Pet's Name:
*
Species?:
*
Dog
Cat
Other
I, the undersigned, hereby state that I am the [legal owner/legally authorized representative of the legal owner] of the above-listed pet and authorized to make all medical decisions regarding this pet. I have declined filling medication(s) through Vets First Choice or other approved pharmacies. I hereby remove Dr. Tamie Haskin and Happier At Home Mobile Veterinary Hospital from any liability related to non-veterinary approved products. I authorize Happier At Home Mobile Veterinary Hospital, at my request, to provide written prescriptions, online authorizations, and/or phoned-in prescriptions for the above-listed pet. I understand that there are fees related to this policy and that they are due immediately upon request of a prescription(s).
*
I understand and agree
Signature
*
Submit
Should be Empty: