Behavioral Medications 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):Alprazolam (Xanax), Amitriptyline, Clomipramine (Clomicalm), Fluoxetine (Prozac)

Wellness testing recommended: MEDICATION MONITORING PROFILE – includes a chemistry profile, CBC (complete blood count) and urinalysis.

Recommended every 6 MONTHS

Risks associated with medication(s): kidney and liver dysfunction.

Discernable adverse effects: anorexia, vomiting, behavioral changes such as aggression in previously unaggressive animals and seizures.

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.

Behavioral Medications Waver

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