Off-Label Medication Consent Form
Clinic Details
- Date
Client's Details
- First name
- Last name
- Phone
Patient's Details
- Name
- DOB (age)
- Microchip
- Weight (kg)
- Gender
- Species
- Breed
- Food-producing species?
About Off-Label Use
Many medications used in veterinary medicine are used "off-label". This means the use falls outside what the product is registered for: a different species, condition, dose, route, or duration, a human-registered product, or a compounded preparation. Off-label use is common, and lawful when directed by a veterinarian, but registered safety and efficacy data may be limited for this particular use and side effects may be less predictable than for on-label use.
Medications
| Medication (brand and active ingredient) | Strength | Dose and route | Frequency and duration | Reason for use (indication) | Why this use is off-label | Notes |
|---|---|---|---|---|---|---|
Consent
I understand that the medication(s) listed above are being used off-label for my animal, and the veterinarian has explained why this use is recommended, the expected benefits, and the possible side effects. I agree to give the medication(s) only as directed, to monitor my animal, and to contact the clinic promptly if I see unexpected signs or side effects. If this animal is a food-producing species, I understand that withholding periods apply as directed by the veterinarian and that produce from this animal must not enter the food chain during them. I confirm that I am over the age of 18 years and am the owner, or an authorised agent of the owner, of this animal.
- Owner / agent name
- Date signed
Owner / agent signature
- Prescribing veterinarian
- Registration number
Veterinarian signature