"*" indicates required fields I the undersigned, have requested a prescription to purchase products from an online pharmacy not associated with American Veterinary Hospital and have been informed that the following risks exist; The manufacturer warranties/guarantees are not valid with internet prescriptions.This means that if your pet is not effectively treated with a product purchased online, the manufacturer will not stand behind the product or liability procedures associated with that product. Rebates through American Veterinary Hospital will not be available for my purchase. There is a possibility that prescription products purchased online or from an outside source may be counterfeit and contain contaminants, or ingredients not approved by the FDA. Products purchased from online pharmacies/outside sources may not have been stored properly, or may be near expiration.Improper storage and expired products greatly, if not completely, reduce the effectiveness of the product. The number of tablets/capsules, milligram size, concentration of liquids and number of authorized refills may differ from the veterinarian’s prescription. As your pet’s medical provider, our medical records track all drugs/products dispensed by our veterinarian(s) to your pet(s).When you purchase prescriptions elsewhere, they may not be tracked in our computer system. This can lead to necessary rechecks being missed and information about adverse reactions and drug interactions not being given. Owner’s InformationName* First Last Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Pet’s InformationPet's Name SpeciesCatDogBreed SexMaleNeutered MaleFemaleSpayed FemaleDate of Birth / Age I understand that I have requested a prescription for veterinary medicines for my pet to be filled at an outside pharmacy.* I understand that I have requested a prescription for veterinary medicines for my pet to be filled at an outside pharmacy. * I have read, understand, and accept the risks associated with purchasing from an outside pharmacy.* I have read, understand, and accept the risks associated with purchasing from an outside pharmacy. * I am aware that American Veterinary Hospital accepts no responsibility for any financial or medical liability incurred from online purchases, not affiliated with our hospital.* I am aware that American Veterinary Hospital accepts no responsibility for any financial or medical liability incurred from online purchases, not affiliated with our hospital. * I understand the doctors and staff of American Veterinary Hospital will not be held responsible for any and all mistakes made by the pharmacy of my choosing.* I understand the doctors and staff of American Veterinary Hospital will not be held responsible for any and all mistakes made by the pharmacy of my choosing. * This includes, but is not limited to, improper dispensing or errors, billing, and any other type of fraudulent or misleading acts. Please Note: The authorization or declining of an outside prescription request may take up to 72 hours after the proper prescription is received by our staff. Owner/Agent's Signature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
