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Owner's Name*

First Last

Pet's Name*

I have requested that my veterinarian at Duvall Veterinary Hospital to write or authorize a prescription for my pet(s) to an alternative pharmacy, rather than obtain the medication/supplement/diet through DVH or their online pharmacy. I understand that any medications and/or products purchased from any other source are under no guarantee or warranty with Duvall Veterinary Hospital.

I agree to not hold Duvall Veterinary Hospital liable for any problems which may occur as a direct or indirect result of my pet’s ingestion or use of a prescription or product purchased from any other source.

I understand that this waiver is only good for one calendar year from the date it was signed, and I will need to sign a waiver annually in order for Duvall Veterinary Hospital to authorize medications and/or products to be purchased from any other source.

Date*

Signature*

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