Telehealth Waiver

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Pet's Name(Required)

Pet's Age(Required)

Pet's Weight(Required)

Pet's Sex(Required)

Male

Female

Species(Required)

Breed(Required)

Color(Required)

Primary Vet Clinic(Required)

How did you hear about us?

Cancellation Policy(Required)

Appointments canceled/rescheduled less than two (2) hours before the appointment time are subject to a cancellation/rescheduling fee up to the full house call price.

Authorization(Required)

I certify I am the legal owner or authorized agent for the owner of the pet described above and give Paws into Grace* and any authorized agents, staff or representatives full and complete authority to examine, prescribe, treat, euthanize and/or provide cremation services for my pet today and/or in the future. I forever release and hold harmless Paws into Grace and any authorized agents, staff or representatives from any and all liability for my pet’s treatment, euthanasia, and/or aftercare, including direct, indirect, or consequential damages resulting from comfort or end-of-life care. I understand Paws into Grace advises against restraining or holding my pet during any injections and I take full responsibility for the outcome. (*Paws into Grace is a business under Benson Veterinary Enterprises, Inc.)

Release & Certification(Required)

I/We agree to release and indemnify Paws into Grace, the Veterinarian, and their owners, members, officers, directors, agents, and employees, from any claim, liability, cost, or expense resulting from their reliance on or services or other performance consistent with the directions, declarations, representations, authorizations, and agreements herein. I/We agree that the liability Paws into Grace, the Veterinarian, and their owners, members, officers, directors, agents, and employees, including without limitation for negligent acts (of itself or its agents or employees), is limited to a refund of the cremations and/or house call fees

TeleHealth(Required)

I/we understand that incorrect usage, including accidental injection, of any/all prescriptions, medications and/or the treatment patch prescribed may cause illness up to and including death, which I acknowledge Paws into Grace is not liable for. I understand that diagnoses and prognosis are limited to the physical examination that the veterinarian is able to perform at my appointment. I acknowledge that further testing may need to be completed to receive an accurate diagnosis/prognosis. I also understand the physical examination of my pet is limited to their temperament and may not be performed if the pet is fractious or aggressive. Paws Into Grace has informed me if additional diagnostics, procedures and/or more aggressive comfort care are recommended for my companion animal at this time, and I assume all responsibility for additional diagnostics, procedures and/or more aggressive comfort care. If I choose to decline recommendations for additional diagnostics, procedures and/or more aggressive comfort care treatment, I assume all responsibility and will forever release and indemnify Paws into Grace.

Medication Waiver(Required)

If the medication does not get used, I understand that I must immediately discard the medication(s) appropriately. 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 administer the medication to my pet as instructed and will not make any changes without first consulting the veterinarian or another member of the treatment team.

Medication Waiver(Required)

I understand that this medication can cause a decreased respiratory drive and may cause enough sedation for my pet to pass after administration. Medications may also cause vomiting, although this usually only occurs once after administration and is rare. I understand that my pet may pass after administration of this medication and I release Paws into Grace of any liability related to my pet’s passing.

Pet Disclosures(Required)

To the best of my knowledge my pet has not bitten, scratched and/or potentially exposed any person or other animal to rabies in the past ten (10) days, is not suffering from rabies, and has not been exposed to other animals suffering from rabies. I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, I consent to any additional fees that may apply.

Acknowledgement(Required)

To the best of my knowledge the information I have provided is accurate and complete. Fees for these services have been explained to me and I assume full responsibility for all charges applicable to such services. I have carefully read and fully understand this form. I accept all of the terms & conditions above.

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Digital Signature Consent(Required)

I accept terms & conditions. Checking the box acts as my digital signature.

Telehealth Waiver

Telehealth Waiver

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