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Dr Duncan HoustonDr Duncan HoustonWritten by a practising veterinarian

Against Medical Advice Waiver Form

A free fillable waiver for when an owner declines veterinary advice and elects a different course of action. Type in the details, sign on screen, then print it or save it as a PDF. Patient and owner details are never stored or sent anywhere.

Waiver

Against Medical Advice

This form records that I, the named and signed person of this form, have chosen to act against the medical advice of the veterinarian associated with this document. I have declined the recommended course of treatment and have instead requested an alternative course of action that is different or less optimal than that recommended.

Treatment

Treatment

(to be completed by the owner/guardian)

Owner

Owner / Guardian Details

Patient

Patient Details

Veterinarian

Veterinarian Details

Member of the Australian Veterinary Association

(tick if applicable)

Declaration

Declaration

I declare that:

  • I am over the age of 18 years
  • I am the owner of this pet OR I am authorised by the owner of this pet to sign this form
  • I understand that by declining the recommended treatment my pet's condition may worsen, and that this may lead to complications, ongoing pain, or death, and I accept this risk
  • I will pay all fees owing at the time of discharge unless alternative arrangements have been made with the veterinarian IN WRITING before signing this form (the written agreement MUST be attached to this form for it to be valid)
  • I recognise that all professional care will be taken of my pet and that I have discussed any concerns I may have with the veterinarian and I hereby release, discharge and indemnify the veterinarian and any person or corporation associated with the hospital from all actions, suits, demands, claims, causes of action and costs of every description whatsoever at law, equity and under statute which I, being the owner of this pet or person authorised by the owner, or any other person or corporation has, may have had or but for this consent form could, would or might at any time hereafter have against the veterinarian or any person or corporation associated with the hospital in respect of or arising directly or indirectly out of the treatment.
  • I have read and understood this form

(if different from above)

(if different from above)

Owner / guardian signature
Witness signature
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Against Medical Advice Waiver Form

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Against Medical Advice Waiver Form

Against Medical Advice

This form records that I, the named and signed person of this form, have chosen to act against the medical advice of the veterinarian associated with this document. I have declined the recommended course of treatment and have instead requested an alternative course of action that is different or less optimal than that recommended.

Date

Treatment

This veterinarian has recommended
I, the owner/guardian of the patient, have declined the above and, against medical advice, instead elect to do the following

Owner / Guardian Details

First name
Last name
Address
Phone
Email

Patient Details

Name
DOB (age)
Microchip
Weight (kg)
Gender
Desexed
Species
Breed
Colour
Markings

Veterinarian Details

First name
Last name
Registration number
Email
This veterinarian is a member of the Australian Veterinary Association and is committed to the professional standards set by that Association as defined by the Code of Ethics

Declaration

I declare that:

  • I am over the age of 18 years
  • I am the owner of this pet OR I am authorised by the owner of this pet to sign this form
  • I understand that by declining the recommended treatment my pet's condition may worsen, and that this may lead to complications, ongoing pain, or death, and I accept this risk
  • I will pay all fees owing at the time of discharge unless alternative arrangements have been made with the veterinarian IN WRITING before signing this form (the written agreement MUST be attached to this form for it to be valid)
  • I recognise that all professional care will be taken of my pet and that I have discussed any concerns I may have with the veterinarian and I hereby release, discharge and indemnify the veterinarian and any person or corporation associated with the hospital from all actions, suits, demands, claims, causes of action and costs of every description whatsoever at law, equity and under statute which I, being the owner of this pet or person authorised by the owner, or any other person or corporation has, may have had or but for this consent form could, would or might at any time hereafter have against the veterinarian or any person or corporation associated with the hospital in respect of or arising directly or indirectly out of the treatment.
  • I have read and understood this form
Signatory first name
Signatory last name

Owner / guardian signature

Witness first name
Witness last name

Witness signature

Date signed
Built by Dr Duncan Houston for Ask A Vet · askavet.com

Nothing typed into this form is sent to or stored by askavet.com. All data stays in your browser and leaves only in the PDF or printout you create. This template is general in nature and is not legal advice. Check the consent and record-keeping requirements of your local veterinary regulator, and have your own legal adviser confirm waiver wording for your practice.

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All 29 certificates and forms
Dr Duncan Houston
About the author

Dr Duncan Houston · BVSc, Veterinarian

Emergency careGeneral practiceMobile vet careFounder, ASK A VET™

Dr Duncan Houston is an Australian veterinarian with experience in emergency, general-practice and mobile veterinary care. He is the founder of ASK A VET™. This guide is educational and is not a substitute for hands-on veterinary care.