Comfort Kit Waiver Pain Treatment with Opioid Medications: Comfort Kit Client Agreement Owner's Name(Required) First Last Pet's Name(Required)I am the owner of the pet listed above, and I understand and voluntarily agree that (check each statement after reviewing):(Required) My pet is being prescribed this opioid medication to be used in case of a pain emergency, prior to a doctor being able to perform humane euthanasia to end or prevent suffering. If the comfort kit is not needed prior to my pet’s passing, I understand that I must immediately discard the medication(s) appropriately. The appropriate way to dispose of medication is to fill a plastic bag with cat litter/sand/dirt/coffee grounds and then squirt medication into the substrate. Then seal the bag and immediately dispose of it in a secure trash receptacle. All needles must also be disposed of properly via a sharps container. I will keep the medicine safe, secure and out of the reach of children and unauthorized adults. If the medicine is lost or stolen or used prior to the anticipated date, I understand it will not be replaced until my next appointment, and may not be replaced at all. I will give my pet the medication as instructed and not change the way I give it without first talking to the doctor or other member of the treatment team. I understand how to give a subcutaneous (under the skin) injection to my pet. If I am unfamiliar with the technique, I will ask for additional instruction and/or demonstration. A video describing the technique can be found here: https://www.youtube.com/watch?v=JrC7VHd-uro. I understand that opioid pain medications can cause a decreased respiratory drive and may be enough sedation for my pet to pass after administration. Opioid pain medications may also cause vomiting, although this usually only occurs once after administration and is very rare with Butorphanol. I will not sell this medicine or share it with others. I understand that if I do, my pet’s treatment will be stopped and that I may be legally held accountable. I will tell the doctor all other medicines that I give my pet, and let him/her know right away if I have a prescription for a new medicine for my pet. I understand that I may lose my right to treatment with this practice if I break any part of this agreement. Select AllDriver's License Number(Required)Driver's License State(Required)Owner's Date of Birth(Required) MM slash DD slash YYYY Consent(Required) I agree to the policies above, and checking this box act as my digital signature.Today's Date(Required) MM slash DD slash YYYY
