Anticonvulsants Waiver

I hereby decline the blood work my veterinarian has recommended every 6 months in order to maintain my animal on prescription medication. I understand the medication my animal is taking may have harmful side effects after prolonged use. I understand the blood work recommended would alert me to any of those harmful side effects before the medication did any permanent damage.

Medication(s):Phenobarbital, Potassium Bromide, Zonisamide

Wellness testing recommended: PHENOBARBITAL LEVEL. Other tests that may be requested are a LIVER PROFILE complete with bile acids and CBC (complete blood count), and/or MEDICATION MONITORING PROFILE – includes a chemistry profile, CBC (complete blood count) and urinalysis.

Additional Test(s):BROMIDE LEVEL – after starting potassium bromide therapy (not needed thereafter).

Recommended every 6 MONTHS

Risks associated with medication(s): Liver damage, liver failure, anemia, thrombocytopenia, and neutropenia. Pancreatitis and/or renal dysfunction may require dosage adjustment.

* Zonisamide is a relatively new medication. Therefore, risks associated with long term use are not fully assessed.

Discernable adverse effects: increased eating, drinking and urination, vomiting, ataxia, tremors, and inappetence and changes in the skin such as ulcerations or cracking. Lower respiratory effects (cough or labored breathing) can be seen in cats.

I am aware of the consequences by not performing this blood work. My veterinarian or representative has spoken with me at length about these risks and has answered all of my questions regarding my pet’s condition and the medication. I will make my veterinarian aware if any of these adverse effects occur and understand that blood work may need to be done at that time.

ANTICONVULSANTS WAIVER
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